APPLICATION. Page 1 of 5. Agent. Retailer: Agent. Address: Montgomery, TX Business Entity: Individual Partnership

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1 APPLICATION FOR GARAGE POLICY Agent Name: Texas Partners Insurance Group Retailer: Agent # Address: Walden Rd, Suite 215C Montgomery, TX Address: Agent Phonee # Proposed effective date: / / to / / Business Entity: Applicant Name: Mailing Address: Individual Partnership Joint Venture Corporation City: : Zip: Other: Insured Contact: Contact Phone #: Description of Operations: Years in business: Years of Experience in this field: Web Site: If new venture, describe prior related experience: Location 1 Address: City: Zip Location 2 Address: City: Zip Location 3 Address: City: Zip INSURANCE HISTORY prior insurance prior losses In the last 3 years has any company cancelled, declined or refused to issue similar insurance to the insured? If yes, explain: Current Carrier Prior Carrier Prior Carrier Eff Date / / Exp Date / / Premium Eff Date / / Exp Date / / Premium Eff Date / / Exp Date / / Premium Loss Driver Loss Driver Loss Driver TYPES OF AUTOS SOLD/ REPAIRED Sales Repair Auto Private Passenger New Auto Private Passenger Used Antique or Classic Autos ATV, Snowmobile, Dirt Bike * Boat or Watercraft * Jet Ski * Busess / Motor Coaches * Contractors Equipment * Emergency Vehicles or Public Livery * Farm Tractors, Implements or Equipment * Golf Carts * Heavy Truck (26,000+ GVW) * Mobile Home Motorcycle or Scooter * Off Road 4x4 * Semi- Trailer * Sports or High Performance RV & Camper (Motorhome) * Trailer (Utility or Travel Trailer) Other: *SPECIALTY VEHICLE SUPPLEMENTAL REQUIRED Sales Repair DO YOU : (Explain All Answers below) Structurally alter vehicles from factory design? Park autoss on public streets? Page 1 of 5

2 Convert vehicles from factory design? Engage in auto or title pawning? Sponsor events for sports, racing, rides, rallies, shows, etc.? Engage in towing for hire? Own, repair, servicee or sponsor a race car? Sell, rebuild or repair autos with a salvage title? If yes, _ of operation & of structural repairs Dismantle Autos or have Salvage Operations? If yes: Are autos stacked more than 3 high? Is there a car crusher on site? Obtain certificates of insurance from all sub-contractors? Loan, lease or rent autos to others? If yes: Loan/ Rent to customer while repairing their auto Do you allow extended or overnight test drives? Radius of pickup and delivery: miles miles How do you transport autos: Owned Tow Truck or Car Hauler Driven by Employees Contracted Tow Truck or Car Hauler Perform Repossession Operations? If yes: For Hire For You Have animals on premises? Have weapons on person/ premises? Sell uninstalled parts or accessories? If yes, Receipts: $ Conduct any other operations? Rent/ Lease to the publicc Explain all yes answers: DEALER OPERATIONS On-premises Nature of Business: Retail Consignment Export Wholesale* Broker* Auction Do you sell over the internet? Advertising Only Sight-Unseen Sales *Wholesalee Supplement Also Required How many vehicles do you sell per year? How many Dealer Plates do you have? Is there a Personal Auto Policy in your household? If yes, what company? Do you offer buy here/ pay here sales? If yes, or if you Export vehicles, when are titles transferred? Are you listed as lienholder on the title? Do salespeople accompany customers on all test drives? If no: Do you require a copy of their Driver s License & Proof of Insurance? Are customers under age 21 accompanied on all test drives? 501-1,000 miles Unlimited Owned Tow Bar or Dolly Temporary or Contract Driver NON-DEALER OPERATIONS Where do you conduct operations? Your Premises _ Customer s Location _ Roadside _ Other Are signs posted to keep customers from work areas? Do you sell any of the following: Gasoline Diesel Fuel LPG Kerosene Fuel Oil Liquefied Natural Gass If yes, Gross Receipts: $ $ $ $ $ $ How many Repair/Transporter plates do you have? _ Do you pick-up or deliver customers vehicles? If yes, how far do you go? Miles How often? Times a week NON-DEALER OPERATONS Auto refers to types of vehicles identified on page 1 Alarm, Stereo or Navigational Systems Alignment Gasoline Station Full Servee Self-Serve Page 2 of 5

3 Airbags Handicap Vehicle Conversion Auto Dismantling Auto Body Shop Auto Painting Auto Restoration Brakes Ground-Up? Breathalyzer / Ignition Interlock Sales, Installation, Service Car Wash: Full Service Self Service Convenience Store Receipts $ Cooking / Restaurant exposure? Lift Kits / Lowering Kits (max # of inches) Oil /Lube Parking Lot or Garage (self-park) Roadside Assistance Roadside Tires If any, completee tire section Safety Inspections Storage/Impound Lot Suspension Transmission Customization and/or Performancee Enhancement Purpose: Go Faster Cosmetic Tires If any, complete tire section: Towing Run Better Trailer Hitch Install or Repair Detailing Engine Repair Fiberglass Body Repair Bolt Weld Tune Ups / Maintenance Valet Parking (Valet supplemental required) Fuel Conversion (CNG, Nitrous): Type: Welding Structural n-structural Frame Work: Straightening Window Tinting Cutting/Stretching Windshield Install or Repair Do you cut between the axles? Other: Are all spray painting operations completed in a separate, ventilated room? Are all paints and solvents stored in a fire resistive cabinet outside the paint booth? Explain if TIRES (Complete if any percentage of Tires above) 1) New Tires Used Tires 5) Do you perform Rim Repair 2) Do you fix/change tires for heavy trucks? If yes: a) Are tires removed? If yes: Recaps/Re-Treads Split Rim Work b) Cosmetic Only? 3) Do you sell Tires over 5 years old? 6) Do you rent or lease Tires? 4) Describe quality assurance to ensure tires are properly installed & inflatedd and all lug nuts properly tightened: AUTO STORAGE AND VALUES Is your lot fully fenced and gated? If no, describe lot security: Security Cameras Building Age: Construction: PC: Central Station Alarm? Other: Are keys secured in a lock box? If no, describe key controls: Owned Autos Held for Sale: n-owned Autos: Value Per Auto: Average Max Valuee Per Auto: Average Max Number of Autos: Average Max Number of Autos: Average Max PEOPLE: LIST ALL OWNERS, EMPLOYEES and DRIVERS (INCLUDE ANY HOUSEHOLD MEMBERS WHO DRIVE YOUR CARS) Page 3 of 5

4 Name Driver s License Number Date of Birth Within the past 3 yrs. Violationss Accidents Status *See Below (1-12) Hours Worked **See Below (F,P,N) Autoo Usage ***See Beloww (A-D) MISSOURI ONLY: Anyone under the age of 21 must be listed on the MUS Driver Exclusion, with the insured s signature. Explain any violations or accidents: Have all owners, employees, drivers & household members of drivingg age been disclosed above? *STATUS Classs I Employees/Regular Operators 1 Active Owner, Partner or Officer 2 Inactive Owner, Partner or Officer 3 Salesperson 4 Manager Class I All Other 5 Lot Person 6 Mechanic 7 Clerical 8 Contract Driver 9 Other: te: EMPLOYEE includes 1099 and other subcontracted persons who work in your Garage Operation and do not have their own insurance. Class II n-employees 10 Spouse of Owner, Partner or Officer 11 Child of Owner, Partner or Officer (14 years of age or older) whether licensed to drive orr not 12 Other: ** HOURS WORKED F Full Time (over 20 hours per week) P Part Time (20 hours or less per week) N n-employee *** AUTO USE A Furnished a covered auto for business and personal use B Drives a covered auto strictly for business & carries a separate personal auto policy C Drives a covered auto strictly for business & DOES NOT carry a separatee personal auto policy D Does not drive a covered auto SCHEDULED AUTOS Year Make Use: P = Personal Model VIN S = Service (used to service the risk itself) Value Loss ee C = Commercial (tow truck for hire) GVW Use Radius Filings Required Check Coverages Desired Page 4 of 5

5 COVERAGE & LIMITS Garage ility Garagekeepers Legal ility Direct Excess Direct Primary Limit of Garage ility Deductible Auto Each Accident Bi & PD Other Than Auto Each Accident Other Than Auto Aggregate Limit Limit of Coverage Location 1 Location 2 Location 3 Maximum Value Per Single Auto Deductible Per Auto Deductible Per Occurrence Comprehensive & Collision Specified Causess & Collision In- Tow Coverage: Limit Per Tow Truck: For Hire t-for-hire Number of Tow Trucks Dealers Physical Damage Comprehensive & Collision Specified Causess & Collision Limit of Coverage Location 1 Location 2 Maximum Value Per Single Auto Deductible Per Auto Location 3 Deductible Per Occurrence Coverage applies to: (Check at least 1) False Pretense Your interest in covered autos you ownn Consigned Autos Your interest and the interest of any creditor as Loss ee (provide name/address below) Dealer s Errors & Omissions ($50,000 Limit) Truth in Lending Odometerr Title Insurance Agents ical ments Uninsured Motorists Underinsured Motorists Personal Injury Protection Auto ical Each Accident Each Accident Limit Per Statute Garage Operations /Premises ical Number of Tags: Dealer Transporter Uninsured Motorists Property Damage _ Radius of Pickup & Delivery ne Miles Miles 501-1,000 Miles 1,000+ Miles Broadened Coverage (includes Personal Injury and $ 50,0000 in Damage to Rented Premises) Hired Auto Damage to Rented Premises Limit Broad Form Products Personal Injury ility (do not select if Broadened Coverage is requested) Drive Other Car Additional Insured Waiver of Subrogation (landlord only) Name Address: Insurable Interest/ Relationship to risk: Additional Information (Include any Related GL Operations you wish to package with the Garage Policy) : 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 factt material thereto commits a fraudulent insurance act, which is a crime and may be subject to civil and criminal penalties. I understand that misrepresentationn or omission of material facts will be cause for cancellation and may void coverage. I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. _ Signature of Agent / Datee Signature of Applicant Page 5 of 5