Service Station Insurance Request
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Reason for insurance request:
New purchase Current owner with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price
Name (First named Insured & other named insured's)
Name of Contact Person:
DBA (Doing Business As)
Proposed Effective Date:
Mailing Address: Please include City, State and Zip
   
Home Telephone: Work Telephone: Fax Telephone:
Email Address:
Business entity:    Year business started:

Premises Information & Characteristics

Location Name:
Street:
City:
State:
Zip:
        
Location Square Feet:   Year Built:
Interest: Owner Tenant    City Limits: Inside Outside
Number of Employees: Full time(Include Self) Number of Employees: Part time
Year applicant purchased or first occupied building
Construction Frame: Number of Stories Number of Buildings
What are the operation's annual gross receipts at this location?
Number of car wash bays ($500 per claim property damage deductible applies)

****Nature of business/description of operations by premise(s)****

(1) Please be very descriptive and DO NOT LEAVE BLANK. Click here for HELP
General Information and underwriting questions
1. Is this a Franchise? Yes No
2. Is this a AAA, ASE, or Gold Class I-Car Certified Shop? Yes No
3. Is there an Automatic Sprinkler System? Yes No
4. Is there a Burglar Alarm? Yes No
5. Is this a Certified Central Alarm? Yes No
6. Is there a Central Station Fire Alarm?Location: Yes No
7. Has any policy been cancelled or non-renewed within the past five years? Yes No
8. During the last five years, has any applicant been convicted of any degree of the crime of arson? Yes No
9. Has the applicant been involved in any lawsuits? Yes No
10. Have any judgements or liens been rendered against the applicant? Yes No
11. Is the applicant a subsidiary of another? Yes No
12. Does the applicant have subsidiaries? Yes No
13.Does the applicant have a website pertaining to these operations?
Yes No
14. Are any of the applicant's operations insured with another company?
 Yes No
15. Does the applicant own or operate any other type of business? Yes No
16.Does the applicant perform maintenance on equipment? Yes No
17.Is a formal safety program in existence? Yes No
18.Does the account present any driving exposures? (e.g., scheduled autos,
auto service/repair, recreational vehicles) If NO SKIP TO QUESTION 22
 Yes No
19. Does the applicant obtain MVR verifications? Yes No
20. Does the applicant have a specific driver recruiting method? Yes No
21. Are there any drivers with moving traffic violations? Yes No
22. Has the applicant had prior insurance?
Yes No
23.Prior Carrier: Effective Date: Expiration Date:
24.Are there any buildings or premises owned or occupied by the applicant but not
described on this application?		 Yes No
25.Are there any off-premises activities or operations? Yes No
26. Have there been any losses or claims relating to allegations of sexual abuse,
molestation or discrimination?
 Yes No
27.Are all smoke detectors, fire extinguishers, and emergency lighting inspected with all records kept? Yes No
28.Are any of the buildings vacant? Yes No
29.Does the applicant service, repair or maintain products of others? Yes No
30.Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material or is there any exposure
to radioactive/nuclear materials? (e.g. landfills, wastes, fuel tanks, etc.)
 Yes No
31.Have any operations been sold, acquired, or discontinued in last 5 years? Yes No
32.Is any machinery or equipment loaned or rented to others? Yes No
33.Are any parking facilities owned or rented? Yes No
34.Are any sporting or social events sponsored? Yes No
35.Are any structural alterations contemplated? Yes No
36.Does the applicant lease employees to or from other employers? Yes No
37.Were the buildings built for other than the current types of occupancies? Yes No
38.Does the applicant sell any vehicles? Yes No
39.Do sales of non-automotive products or services exceed 10% of total receipts? Yes No
40.Is any work done on heavy trucks, truck tractors, recreational vehicles,
motorcycles or farm machinery?		 Yes No
41.Is any work done to modify or customize autos, mechanically or in appearance? Yes No
42.Is any work done on high performance vehicles or vehicles used in racing or competitive events? Yes No
43.Does the applicant operate a truck or equipment rental operation, such as U-Haul or Ryder? Yes No
44.Is any towing done by the applicant? Yes No
45.Does the applicant do any brake work? Yes No
46.Does the applicant pick up or deliver customers' vehicles? Yes No
47.Does the applicant have any guard dogs? Yes No
48.Does the applicant fill LP tanks? Yes No
49.Is any building occupied in whole or in part for manufacturing or processing?
 Yes No
50. Are paints or other flammable liquids stored in approved cabinets or containers?
 Yes No
51. Have the roof, wiring, heating, and/or plumbing systems been updated since original Construction?
 Yes No

Please List Updates
Year Roof was Updated? Roof Type: Year Wiring was Updated?
Year Heating was Updated? Year Plumbing was Updated?  

Describe the exposures and distance to the right of premisis building.
 (Who/What is next to your business)    

Describe the exposures and distance to the left of building
(Who/What is next to your business)    
Describe the exposures and distance to the rear of building
(Who/What is next to your business)

Auto Service (Awnser these questions if your operations include auto service)
1. Is storage lot(s) fenced? Yes No
2. Are keys to the customer's autos out of sight or locked away? Yes No
3. Are any loaner or rental vehicles provided? Yes No
4. Does the premises have any heating source that is not suspended more than
8 feet above floor level?		 Yes No

Please explain any Yes answers:

Loss History

Check this box if you have NO losses in the last 5 years:
Lost history information: Please list dates, description of claim, amount paid, and claim status.
Liability Coverage Requested
General Aggregate Liability Coverage Recommended $2,000,000
Products & Completed Operations Aggregate Recommended $1,000,000
Personal & Advertising Injury Recommended $1,000,000
Each occurrence Recommended $1,000,000
Fire damage (any one fire) Recommended $100,000
Medical expense (any one person) Recommended $5,000
Business Personal Property Can vary depending on size
Building Coverage Can vary depending on size
Product / Completed Operations:
  Annual Gross Sales
$ (or projected sales)		 Annual Payroll:
Additional Interest/Certificate Receipt
 Additional Insured  |   Loss payee  |   Mortgagee |    Lien holder  |   Employee as Lessor
Name and Address
Name and Address
Please let us know the best time to contact you:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.