Garage Keepers, Auto Repair, Service Stations

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Caroline Lawson
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1 Grge Keepers, Auto Repir, Service Sttios Applict Nme: Retl Opertios: Plese provide the detils of this opertio i rrtive preseted with this pplictio. o you operte Retl or Lesig opertio t y loctio scheduled o this policy? Q Q o you hve Geer! Libility Policy i plce coverig this opertio? Q Storge Opertios: Grge Keepers Questioire: Lot 1 Storge Fcility: Completely Feced? Completely Lighted t Night? ' Surveillce Cmer Equipped? Is the fcility equipped \vith Itrusio Alrms? Lot Atteded urig Busiess Hours? Gurd/Night wtchme o duty t ight? Fire Extiguishers re ccessible t ech yrd? Customer's Keys re kept locked i secure loctio? Grge Keepers Questioire: o you deliver or pickup customer's vehicles by drivig the uto? Are ALL buildigs equipped with sprikler protectio? Are ALL buildigs supplied with the proper type d umber of fire extiguishers? Q d HH d G Q Lot 2 Lot3 Service Sttio Opertios: Plese provide the detils of this opertio pplictio. i rrtive preseted with this o you hve Geerl Libility Policy hi plce coverig this opertio? U Volutry Repossessio: Plese provide the detils of this opertio i pplictio. rrtive preseted with this Who issues the ssigmet to pickup cr? Wht portio of the totl reveue does this opertio represet? % Hs the debtor bee properly otified d greed to the surreder of the vehicle? U Pge 1 of4

2 Applict Nme: Auto Repirs: Grge Libility Questioire: o you sell used uto prts? Q Q o you sell d istll tires? Newd Used d o you sell mufctured recpped tires for privte or commercil vehicles? Q Q Are ALL of your service d repir mechics Professiolly Certified? Q Q o you ow or lese y cres? d o you perform y type of weldig t y loctios scheduled o this policy? d o you hve y dogs o premises durig or fter hour? d o you hve gs sles t y loctio scheduled o this policy? d d Are there y uder groud storge tks t y loctio scheduled o this policy? d d o you ow or lese out limousies, v, or buses? d d o you ow or operte cr wsh t y loctio scheduled o this policy? Q Q o you restrict the public from eterig your grge work re? d Q o you provide re for customers to wit while their vehicle is repired? d d o you operte Coveiece Store t y loctio scheduled o this policy? d d Is the fcility ispected by govermetl gecy o ul bsis? d d o you reti writte records o ll repirs performed by your opertio? d d Wht portio of the totl reveue does this opertio represet?, % Are repirs performed o privte psseger utos? d d Are repirs performed o commercil utos or hevy equipmet? Q "d o you ow, sposor, or work o "rce crs"? d d escribe the types of the repirs performed? How my service bys do you hve? How my of those bys hve lift system for hoistig utomobiles? o you egge i the d Sle or d Service of: Q ATV's dmotorcycles dgry Mrket Vehicles dbot's dstretch Vehicles rjkit Crs 's dv Coversio Slvge, Scrp Metl or Jukyrd: Plese provide the detils of this opertio i rrtive preseted with this pplictio. o you hve Geerl Libility Policy i plce coverig this opertio? d d o you or hve you ever owed or lesed crushig mchie? d d o you llow third prty vedors to perform crushig o your property? d d Wht portio of the totl reveue does this opertio represet?. % Pge 2 of4

3 Applict Nme: Truck/Equipmet.Hulig: Plese provide the detils of this opertio i rrtive preseted with this pplictio. o you hve cotrcts to hul goods for specific customers? Are ll drivers performig this work CL Clss "A" licesed drivers? Wht is the MAXIMUM distce for these trips?. riles Wht portio of the totl reveue does this opertio represet?^ % Q Wht commodities do you hul? Auto Body Shop: Plese provide the detils of this opertio i rrtive preseted with this pplictio. o you hve pit booth? o you hve UL pproved Pit Booth? o you pit crs outside of the booth? o you hve Frme Strighteig Mchie? o you weld y prts together durig repir? Wht portio of the totl reveue does this opertio represet? % Q Q FJ Plese provide the me d descriptio of the Frme Strighteig Mchie. Ivolutry Repossessio: Plese provide the detils of this opertio i rrtive preseted with this pplictio. o you perform Ivolutry Repossessios? The Policies re Subject to Audit: Loctio 1: Geerl Libility Sectio: epedig o the Crrier, Geerl Libility my replce Grge Libility o our policies. Plese complete the followig questios tht perti to the grge opertios. Auto Repir d Body Shops (10073) Gross Reveues: $ Automobile Prts (10071) (New or Icidetl Exposures Oly) Gross Reveues: S Buildig t Fully Occupied by the Isured (45539) (Lessor's Risk Oly) Squre Footge: Storge Opertios (46622) (Storge Are Icludig the iside grge) Storge Are: Tire elers (18616) (Icidetl Exposures Oly) Gross Reveues: $ Trucker (99793) (Tower with Storge Lot or Repir Exposure "Pure Tower") (Gross Pyroll other th drivers) Gross -river Pyroll:: S Vct Buildig (68606) (Other th t for Profit) Vct Ld (49451) (Other th t for Profit) Additiol Exposures re subject to uderwriter pprovl: Other Exposures: ISO Geerl Libility Code: Squre Footge: Squre Footge: escriptio:, Pge 3 of4

4 Applict Nme: The Policies re Subject to Audit: Loctio 2: Geerl Libility Sectio: epedig o the Crrier, Geer) Libility my replce Grge Libility o our policies. Plese complete tbe followig questios tht perti to the grge opertios. Auto Repir d Body Shops (10073) Gross Reveues: $ Automobile Prts (10071) (New or Icidetl Exposures Oly) Gross Reveues: $ Buildig t Fully Occupied by the Isured (45539) (Lessor's Risk Oly) Squre Footge:. Storge Opertios (46622) (Storge Are Icludig the iside grge) Storge Are: Tire elers (18616) (Icidetl Exposures Oly) Gross Reveues: $ Trucker (99793) (Tower with Storge Lot or Repir Exposure "Pure Tower") (Gross Pyroll other th drivers) Gross -river Pyroll:: _ Vct Buildig (68606) (Other th t for Profit) Vct Ld (49451) (Other th t for Profit) Additiol Exposures re subject to uderwriter pprovl: Other Exposures: ISO Geerl Libility Code: Squre Footge: Squre Footge: es criptio: These Policies re Subject to Audit: Loctio 3: Geerl Libility Sectio: epedig o the Crrier, Geerl Libility my replce Grge Libility o our policies. Plese complete the followig questios tht perti to the grge opertios. Auto Repir d Body Shops (10073) Gross Reveues: $ Automobile Prts (10071) (New or Icidetl Exposures Oly) Gross Reveues: S Buildig t Fully Occupied by the Isured (61217) (Lessor's Risk Oly) Squre Footge: Storge Opertios (46622) (Storge Are Icludig the iside grge) Storge Are: Tire elers (18616) (Icidetl Exposures Oly) Gross Reveues: $ Trucker (99793) (Tower with Storge Lot or Repir Exposure "Pure Tower") (Gross Pyroll other th drivers) Gross -river Pyroll:: $ Vct Buildig (68606) (Other th t for Profit) Vct Ld (49451) (Other th t for Profit) Additiol Exposures re subject to uderwriter pprovl: Other Exposures: ISO Geerl Libility Code:, Squre Footge: Squre Footge: es criptio: Pge 4 of4

5 AGENCY CUSTOMER I: PATE (M M//YYYY1 AGENCY Wright IsurcQ Agecy POLICY NUMBER EFFECTl VH ATE NAME INSURE(S) CARRIER '. NAICCOE COVERAGES / LIMITS RIVER INFORMATION ACOR 163 ttched for dditiol drivers LIST ALL RIVERS, INCLUING FAMILY MEMBERS THAT WILL RIVE COMPANY VEHICLES, AN EMPLOYEES WHO RIVE OWN VEHICLES ON COMPANY BUSINESS. RIVER # NAME (Iclude ddress, [f required) SEX vlafl itat ATE OF BIRTH YRS EXP YEAR LIC RIVERS LICENSE NUMBER/ SOCIAL SECURITY NUMBER STATE LIC ATE HIRE BROAEN NO-FMILT OC USE VEH# % USE GENERAL INFORMATION EXPLAIN ALL "YES- RESPONSES 1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY OWNE BY AN REGISTERE TO THE APPLICANT? NAME OF OTHER OWNER NAME OF OTHER OWNER 2. O OVER 50% OFTHE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS? 3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION? 4. AREANYVEHICLESLEASETOOTHERS? 5. ARE ANY VEHICLES CUSTOMIZE, ALTERE OR HAVE SPECIAL EQUIPMENT? ESCRIPTION VEH# ESCRIPTION 6. ARE ICC, PUC OR OTHER FILINGS REQUIRE? (If'YES", ttch ACOR 194) 7. O OPERATIONS INVOLVE TRANSPORTING HAZAROUS MATERIAL? ACOR127 (2009/01) Attch to ACOR ACOR CORPORATION. All rights reserved. The ACOR me d logo re registered mrks of ACOR

6 GENERAL INFORMATION (cotiued) AGENCY CUSTOMER I: EXPLAIN ALL 'YES1' RESPONSES 8. ANY HOL HARMLESS AGREEMENTS? 9, ANY VEHICLES USE BY FAMILY MEMBERS? IF SO, IENTIFY. 10. OES THE APPLICANT OBTAIN MVR VERIFICATIONS? 11. OES THE APPLICANT HAVE A SPECIFIC RIVER RECRUITING METHO? 12. ARE ANY RIVERS NOT COVERE BY WORKERS COMPENSATION? 13. ANY VEHICLES OWNE BUT NOT SCHEULE ON THIS APPLICATION? 14. ANY RIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS? APPLICABLE ONLY IN KANSAS: UNER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRE TO BE REPORTE TO INSURERS; 1. A speedig violtio of up to six (6) iriph thi occurs I sre with 3 mximum posted speed Hmlifrom 3 mph ihrough S4 mph, or 2. A speedig violtio of up to te (10) mprt tht occurs I re with mximum posted speeil limit from SB mph through 70 mph. RV# ATE(MW/YYYY) TYPE PLACE (CITY, STATE) 15. HAS AGENT INSPECTE VEHICLES? 16. ARE ALL VEHICLES TO BE INCLUE IN THIS POLICY PART OF A FLEET? ESCRIPTION OF GARAGE / STORAGE LOCATIONS MAXIMUM OLLAR VALUE SUBJECTTO LOSS AITIONAL INTEREST / CERTIFICATE RECIPIENT INTEREST AITIONAL INSURE EMPLOYEE AS LESSOR UENH OLER LOSS PAYEE OWNER REGISTRANT ACOR 45 ttched for dditiol mes NAMEAN ARESS CERTIFICATE INTEREST IN ITEM NUMBER REFERENCE / LOAN ft AITIONAL INSURE EMPLOYEE AS LESSOR UENH OLER LOSS PAYEE OWNER REGISTRANT NAME AN ARESS CERTIFICATE INTEREST IN ITEM NUMBER REFERENCE / LOAN ft REMARKS (Attch ACOR 101, Additiol Remrks Schedule, if more spce is required) ACOR127 (2009/01) Pge 2 of 3

GENERAL INFORMATION. (b) Have you ever been cancelled or non-renewed for this kind of insurance? Yes No If yes, explain

GENERAL INFORMATION. (b) Have you ever been cancelled or non-renewed for this kind of insurance? Yes No If yes, explain Trailer Dealer Application COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY OF THE SOUTH