Applicant s Name: Submission Requirements:

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1 AutoServiceGuard Supplemental Questionnaire WILLIS PROGRAMS PROGRAM ADMINISTRATOR 4211 W. Boy Scout Blvd., Tampa, FL Phone: Fax: Agency: Producer: Applicant website: Applicant s Name: Effective Date: Quote Need by Date: Submission Requirements: 1) Lead Time complete submission required 10 days prior to quote need by date. 2) In addition to this Supplemental Questionnaire (signed by the insured), a complete submission includes: ACORD Applications completed for all lines of coverage s requested. o ACORD 125 (signed by the insured and producer) o and minimum of Property and General liability lines are required Currently Valued Loss Runs (current year, plus prior three years) including a description of any incurred claim over $10,000. Employee list including all owners, employees with driving duties including date of birth, driver s license number and job duties. Recent MVR if available. 3) General Liability exposure is subject to audit. Note: If the incumbent carrier is one of the Nationwide Companies we will not be able offer a quote. The Program is not available in AZ and HI; commercial auto coverage is not available in MA or NJ. General Information Number of years in business: Number of years at this location: Operations of the applicant (check all that apply): Automobile Quick Lubrication Services Automobile Repair, Service or Body Shop Car Wash and Detailing Convenience Store/Gas Station Is the business open 24/7? Yes No Other: Describe: Full Service Gas Stations Travel Plaza/Truck Stop Trailer Repair including Heavy Truck Transmission, Muffler and Brake Businesses with these operations are not eligible for the program: New or Used Auto Sales Emergency Vehicle Repair Boat, RV, Motorcycle, ATV, PWC Repair Retail/wholesale tire and auto parts stores Bus Service or Repair Auto dismantling, salvage yards, repossession operations Note: Liquor Liability & Equipment Breakdown coverages are not available in the program

2 Property Section MS AS 01 (or State equivalent) Auto Service Risks (Property Coverage extensions) is included. Optional increased limits are available as follows: Premises No.: Building No.: Included: Limit of Ins. Increased Limits Available 1. Fire Department Service Charge $5,000 $ $7,500 or $10,000 limits 2. Money and Securities $2,500 $ maximum limit $10, Outdoor Signs $5,000 $ maximum limit $250, Valuable Papers and Records $5,000 $ maximum limit $250, Employee Tools $2,500 $ $5,000, $7,500 or $10, Accounts Receivable $5,000 $ maximum limit $250, Employee Dishonesty $5,000 $ maximum limit $10,000 Premises No.: Building No.: Included: Limit of Ins. Increased Limits Available 1. Fire Department Service Charge $5,000 $ $7,500 to $10,000 limits 2. Money and Securities $2,500 $ maximum limit $10, Outdoor Signs $5,000 $ maximum limit $250, Valuable Papers and Records $5,000 $ maximum limit $250, Employee Tools $2,500 $ $5,000, $7,500 or $10, Accounts Receivable $5,000 $ maximum limit $250, Employee Dishonesty $5,000 $ maximum limit $10,000 Garagekeepers - Loss or Damage to Customers Autos Select Coverage Requested: Direct primary coverage for loss or damage to customers autos (MS AS 02) Legal liability coverage for loss or damage to customers autos (MS AS 03) Requested Limits and Deductibles Loc. 1 Loc. 2 Enter the Limit for Each Location (maximum value of all autos in your C.C.C) Maximum number of vehicles in your C.C.C $ $ Other than Collision deductible per each customer s auto $ $ Other than Collision maximum deductible per any one event $ $ Collision deductible per each customer s auto $ $ 1. Where are customers autos kept at night? Inside % Outside % 2. If autos are kept outside, is lot protected on all sides by fence, chain, cable or pipe welded to or connected through steel, concrete or heavy timber post and secure with a heavy gauge steel padlock? yes no a. If no, explain: 3. Where are keys to customers vehicles kept? MS AS 05 Loss or Damage to Lessors Property: Loc. 1 Loc. 2 Description of Premises Description of Leased Property Name of Lessor Limit of Insurance per Occurrence (maximum limit $100,000) $ $

3 MS AS 06 (or state equivalent) Hired Auto and Non-Owned Auto Per Occurrence Limit of Insurance Coverage (maximum per occurrence limit $1,000,000 Non-Owned Auto Liability No. of Employees: $ General Liability Section 1. Does applicant have any owned commercial vehicles? Yes No 2. Does applicant rent / loan autos while customers autos are left for service / repair? Yes No a. If yes, explain: 3. Does applicant pick up or deliver automobiles? Yes No a. If yes, indicate radius in miles: 50 mi % % over 200 % 4. Is the parking area lighted at night? Yes No 5. Are there any dogs on premises? Yes No 6. Advise if applicant performs any of the following operations: Airbag installation, servicing or repair? Yes No Aircraft servicing or repair? Yes No Alternative fuel conversions (butane, propane or liquid petroleum) Yes No Auto rebuilding? Yes No Boat service or repair? Yes No Contractor s equipment service or repair? Yes No Farm equipment or repair? Yes No Frame straightening? Yes No Heavy truck service or repair? Yes No Impound storage lots? Yes No Leasing or renting of vehicles or equipment? Yes No Major engine or body repairs? Yes No Mobile equipment service or repair? Yes No Spray Painting Operations? Yes No If yes is the spray paint booth NFPA approved? Yes No Explain the extent of painting operations: Tow truck operations? Yes No If yes does the insured Repossess Vehicles Yes No Trailer Hitch Installation or Repair? Yes No If yes, advise percentage of gross receipts: % 7. Do you tow for hire? Yes No 8. If you have a lube pit, are nets present over pits? Yes No 9. Auto or Van conversions/modifications: Yes No Indicate type of work performed and/or equipment installed: Air Conditioners High valued electronics Heaters or Stoves Chair lifts Hydraulic suspension systems Structural Chassis Performance Suspension Frame Physically disabled controls Tanks Handling Characteristics Refrigerators Other (describe)

4 Convenience Store and Cooking Exposures A. Are procedures displayed and followed to verify age of customers buying tobacco? Yes No B. Are ID s checked to verify age of customers buying liquor or alcohol? Yes No C. Are firearms kept for protection or sold at the store? Yes No D. Are signs posted on the premises prohibiting the consumption of alcohol on premises? Yes No E. If a car wash is present, are barriers erected and signs posted to prohibit foot traffic? Yes No F. How often does the owner inspect the car wash? Weekly Monthly Bi-Monthly Annually G. If the car wash is a drive-thru, are signs posted that the company is not liable for vehicle damage and that autos with non-standard equipment should not use the car was or with vehicle damage? Yes No H. Are there any operations other than yours taking place on the premises? (i.e. food stands/trucks, free-lancing carwashes, detailing, etc.) Yes No I. If LP is sold, is it exchanged or refilled? Exchanged Refilled NA 1. If refilled, does an employee fill the tanks or does the customer? Employee Customer 2. Are there protective barriers around all LP tanks and tank storage boxes? Yes No J. Is there cooking or food preparation on the premises? (if yes, answer 1 through 6 below) Yes No 1. Sub-let to a Franchise? Yes No, if yes Brand: 2. Types of food preparation: Microwave Grill Fryer Deli Pizza Oven Salad 3. Does cooking equipment have automatic gas/electric shut-off with manual pull? Yes No 4. Are filters professionally cleaned at a minimum of every 6 months? Yes No 5. Are portable extinguishers mounted and accessible to cooking areas? Yes No 6. Is on premises seating available? Yes No K. Do you have any ATMs on your premises that are owned by you? Yes No 1. If yes, do you have a surveillance camera specifically for the ATM? Yes No 2. Does the cashier have a panic button connected to the policy or Central Station? Yes No This questionnaire does not bind YOU nor US to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in- surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

5 NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK (OTHER THAN AUTOMOBILE): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK (AUTOMOBILE): Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. APPLICANT S Name and Title: (Please type or Print) APPLICANT S SIGNATURE: DATE: (Must be signed by an active owner, partner or executive officer) PRODUCER S SIGNATURE: DATE: AGENT NAME: AGENT LIC. NO: (Applicable to FL Agents Only)