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Asia Insurance Business Garage Keepers Quote

Customer Information
Business Name
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Work Phone	Email

Business Information
Years in Business		Years Sales/Repair Experience
Business Entity	Individual	Partnership	Corporation
Describe your Operations
Locations where you conduct Garage Operations
Location 1
Location 2

Driver information #1
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations
Add another driver Yes No

Driver information #2
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations
Add another driver Yes No

Driver information #3
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations
Add another driver Yes No

Driver information #4
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations
Add another driver Yes No

Driver information #5
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations
Add another driver Yes No

Driver information #6
Full Name
Driver's license		State of license
Date of birth		Furnished auto	Yes No
Job Description and / or Relation
Past 3 Years Number of	Accidents	Citations

Sales
Where do you purchase vehicles?
Who drives or tows vehicles to your lot?
How many times per year do you drive-away more than 300 miles from point of purchase?
How many vehicles do you sell per year?
How many of those are on consignment?
What is your normal radius of operation?
What is your sales mix?
a. cars, sport utility, pickups, vans	%	d. trucks, tractors, semi-trailers	%
b. motor homes	%	e. salvage parts	%
c. travel trailers, camp trailers	%	f. other	%
Describe your theft barriers (fence & gate or post & cable)
Describe your key controls
How many dealer plates do you have?
Do you repossess vehicles?	Yes No
If yes, explain
Do you sell "salvage titled" vehicles?	Yes No
If yes, what percentage of vehicles require
cosmetic repair	%	mechanical repair	%
structural repair	%
Do you always ride along on test drives?	Yes No

Services
What percentage of your work is
Body/Paint	%	Muffler	%
Tune Up	%	Radiator	%
Transmission	%	Wheel Alignment	%
Brakes	%	Oil & Lube	%
Sound System	%	Window Tint	%
Tires	%	Upholstery	%
Wash/Detail	%	Other	%
Describe
Do you sell gasoline?	Yes No	If yes, how many gallons?
or LPG?	Yes No	If yes, how many gallons?
Do you install trailer hitches?	Yes No
Do you have a spray paint booth?	Yes No
If yes, is it U/L approved?	Yes No	Is it ventilated?	Yes No
Do you recap tires or sell recapped tires?	Yes No
Do you tow for hire?	Yes No
If yes, explain
Describe lot security and key controls

Prior Carrier and Loss History for 3 Years
Current Carrier
Policy Period
Policy Premium
Prior Carrier
Policy Period
Policy Premium
Prior Carrier
Policy Period
Policy Premium
Date of Loss		Amount
Description of Loss
Date of Loss		Amount
Description of Loss
Date of Loss		Amount
Description of Loss

Coverage Requested

Garage Liability

Each accident

Aggregate, Deductible

(Legal Liab.) Garage-keepers

$ per location

SCL

$ deductible

Collision

$ deductible

Dealers Physical Damage

$ per location

SCL

$ deductible

Collision

$ deductible

Type

New

Used

Interests Covered

Owner

Owner and Creditor

Consignment Owner

Premises Medical Payments $1,000

Specifically Described Autos:

Veh.No.	Year	Make
Body Type	ACV	V.I.N.
Veh.No.	Year	Make
Body Type	ACV	V.I.N.
Veh.No.	Year	Make
Body Type	ACV	V.I.N.
Veh.No.	GVW	Radius
Use	Loss Payee
Veh.No.	GVW	Radius
Use	Loss Payee
Veh.No.	GVW	Radius
Use	Loss Payee

Uninsured Motorist

Personal Injury Protection

Fire Legal Liability

$ 50,000

Buy-backs

GK Transit Limit

Drive-Away Miles

Value per Auto

Please use the space below to add comments regarding any special circumstances or coverage needs

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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