1) GENERAL INFO
CITY
STATE
ZIP
DAYTIME
FAX
GENERAL INFO
Locations where you conduct Garage Operations:
Underwritting Information List of Drivers (Owners, Employees, Family)
Driver 1
Accidents
Citations
Driver 2
Accidents
Citations
Driver 3
Accidents
Citations
Driver 4
Accidents
Citations
Driver 5
Accidents
Citations
Driver 6
Accidents
Citations
Sales
% cosmetic repair
% mechanical repair
% structural repair
Services

What Percentage of your work is.....

Prior Carrier and Loss History for 3 Years
Coverage Requested
per location
deductible
deductible
per location
deductible
deductible
Vehicle 1
Veh.No.
Year
Make
Body Type
ACV
V.I.N
Vehicle 2
Veh.No.
Year
Make
Body Type
ACV
V.I.N
Vehicle 3
Veh.No.
Year
Make
Body Type
ACV
V.I.N
Vehicle 4
Veh.No.
GVW
Radius
Use
Loss Payee
Vehicle 5
Veh.No.
GVW
Radius
Use
Loss Payee
Vehicle 6
Veh.No.
GVW
Radius
Use
Loss Payee
Fire Legal Liability: $ 50,000 BUY-BACKS:
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