Plan Administrator: Pearl Autoshield Plus Application 1200 E. Glen Ave., Peoria Heights, IL 61616-5348 Questions: Please call 888.619.2012 *To be able to save this form after the fields are filled in, you will need to have Adobe Reader 9 or later. If you do not have version 9 or later, please download the free tool at: http://get.adobe.com/reader/ General Information FEIN#: Applicant Name: Doing business as (DBA): Mailing Address: City: State: ZIP: Website Address: Contact Name: Contact Phone: Effective Date: Expiration Date: Years in Business: If less than 3 years, please provide industry experience: Lines of Business Property Garage/Auto Workers Comp EPLI Umbrella Legal Status Individual Partnership Corporation LLC Description of Operations Franchise auto dealer Non-franchise auto dealer Non-dealer (describe below) General Rating Information Coverage Symbols Limits/Deductibles Liability 21 22 23 24 27 28 29 32 PIP (Mandatory in DE, FL, KS, KY, MD, MI, MN, NJ, NY, ND, OR, PA, UT) 25 27 Each accident limit $ Aggregate limit $ Deductible $ Medical 22 23 24 27 32 $ Uninsured 22 26 27 $ Underinsured 22 26 27 $ Garagekeepers Specified perils Comprehensive Collision Physical damage Specified perils Comprehensive Collision 30 32 Per auto deductible $ Per occurrence deductible $ 27 28 31 32 Per auto deductible $ Per occurrence deductible $ Page 1 of 7
Miscellaneous Coverage Information Coverage Desired Limits Valuation/Deductible EPLI: Enhanced Standard $ Deductible $ Umbrella $ $10,000 SIR mandatory Location Information Location #1 Same as mailing address Other, see below Address: City: State: ZIP: Employee Count (Complete employee list required.) Class of Employee Class 1A Owners/employees furnished an auto for personal use & all employees whose principal duty it is to operate an auto Class 1B Full-time salespeople and managers not furnished an auto for personal use Class 1B Part-time salespeople and managers not furnished an auto for personal use Total Employees Class 1C All others full-time (If the insured does not have dealer plates, use this class for all employees.) Class 1C All others part-time Non-employee under age 25 Non-employee all other Garagekeepers: Garagekeepers limit at this location: $ Direct primary Legal liability Comprehensive deductible: $500/$2,500 $1,000/$5,000 $2,500/$12,500 $5,000/$25,000 Collision deductible: $500 $1,000 $2,500 $5,000 Average retail value of autos serviced: $ Average number of customer autos in your custody at a time: Maximum number of customer autos in your custody at a time: Dealers Open Lot: Dealers open lot limit at this location: Comprehensive Collision Standard open lot * Non-standard open lot ** Building * Standard open lot: open parking or storage lots enclosed on all sides by a metal cyclone fence not less than six feet in height or bounded on one or more sides by the wall or walls of a building with no unprotected opening and with exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with opening securely locked when unattended. ** Non-standard open lot: any other type of protection or fencing or unprotected lot. Comprehensive deductible: $500/$2,500 $1,000/$5,000 $2,500/$12,500 $5,000/$25,000 Collision deductible: $500 $1,000 $2,500 $5,000 False pretense: If "Yes," limit requested: $ Average value of autos for sale: $ Average number of autos for sale: Largest single sale within the last 18 months: $ Year, make, and model (if sale was over $75,000): / / Page 2 of 7
Additional garage coverages: Property Location #: Building #: Description: Square feet: Year built: Number of stories: Building updates: Plumbing: Year of update: HVAC: Year of update: Electrical: Year of update: Roof: Year of update: Construction: Frame JM NC Masonry NC Modified fire resistive Fire resistive Is the building sprinklered? Does the building have a fire alarm? Local alarm Central station Does the building have a burglar alarm? Local alarm Central station Deductible: $500 $1,000 $2,500 $5,000 $10,000 Co-insurance: 80% 90% 100% Property/Inland Marine/Crime Coverages Desired Limits Valuation/Deductible Building Personal property of the insured $ Business income $ $ RC ACV Other $ Deductible $ RC ACV Other $ Deductible $ Employee tools $ Deductible $ Employee dishonesty $ Deductible $ Forgery $ Deductible $ Money/securities (inside and outside) $ Deductible $ Other: $ Deductible $ What are the annual sales for this location? Garage/Auto Coverage Information Garage/Auto Coverage Options Limits Non-owned Included automatically for Pearl Autoshield Plus program Hired Included automatically for Pearl Autoshield Plus program Drive other car coverage List names: Dealer plates Number of plates: On hook coverage Limit $ Deductible $ Dealers E&O Limit $ Auto dealers legal defense & product related damages Limit $ Other: Page 3 of 7
Garage/Auto Coverage Information Scheduled Vehicles List all scheduled vehicles to be included under this policy. (For additional vehicles, complete vehicle supplemental.) If customer loaners are scheduled on the policy detail, indicate which autos are loaners in the USE column. Year Make Model Cost new VIN ZIP Radius Use COMP DED COLL DED Business Personnel List all owners/officers, employees, drivers, sub-contractors, and buyers using your license. Name License number State DOB Position STATUS Personal use Non-Business Personnel LIst all spouse(s), household/family members, and children between the ages of 14 and 25. Name License number State DOB Relationship Personal use Page 4 of 7
Survey of Hazards General Underwriting Questions 1. Does applicant share a premises with any other occupants? 2. Are there any guard dogs on premises? 3. Is applicant a subsidiary of another entity or have any subsidiaries? 4. Does applicant subcontract any work? 5. Has coverage been declined, canceled, or non-renewed in the last 3 years? 6. Does applicant have any other business ventures not included in this submission? 7. Has applicant had a foreclosure, repossession, or bankruptcy in the last 5 years? 8. Has applicant had a judgment in the last 5 years? 9. Are there currently serviced, charged, and operable fire extinguishers on premises? 10. Does applicant store all flammable liquids in a UL-listed fire cabinet? Not needed 11. Does applicant use UL-listed metal containers with self-closing lids? Not needed 12. Does applicant have "No Smoking" signs posted? 13. Employee safety training practices: Informal Weekly meetings Monthly meetings Other 14. Indicate number of mechanic certifications. ASE certified technicians: I-Car certified technicians: 15. Describe key control procedures: 16. Does applicant have underground gasoline storage tanks? If "Yes," please explain. Age of tanks: Tank construction: Describe leak monitoring method: 17. Does applicant rent or lease vehicles to the public? If "Yes," does the applicant have a separate liability and physical damage policy in place for this operation? 18. Do you use owned vehicles to tow/haul other vehicles or trailers? If "Yes," the vehicle responsible for the towing/hauling needs to be scheduled on our policy for liability coverage to apply. Crime Coverage Is there an audit by? CPA Public Accountant Staff Other Audit frequency: Annual Semi-Annual Quarterly Other Does audit include inventory? Are bank accounts reconciled by someone not authorized to deposit or withdraw? Is countersignature of checks required? If not, who signs controls? Audit report is rendered to: Owner Partners Board of Directors Other Are bank deposits made daily? Is night depository used on Saturday if depositing after bank hours? Are checks stamped FOR DEPOSIT ONLY? Do you ever have more than $1,000 in cash at your premises? If "Yes," do you have a safe to store the cash in? Safe Class: Page 5 of 7
Types of Vehicles Sales % Repair % Type of Vehicles % % Private passenger autos, pickups, vans, SUVs % % RVs, motorhomes, campers (include supplement) % % Heavy truck/semi-trailers (include supplement) % % Boats (describe): % % Power sports (jet skis, ATVs, UTVs) % % Motorcycles (include supplement) % % Golf carts % % Antique or classic cars % % Bucket trucks, man lifts % % Contractors equipment (describe): % % Agricultural equipment/farm implements (describe): % % Emergency vehicles (describe): % % Buses (include supplement): % % Trailers (other than semi) % % Other (describe): % % Total percentage all operations combined should equal 100% Dealer Operations Percentage of new autos vs. used autos: New: Used: If non-franchise, is applicant part of the National Independent Auto Dealers Association or a Certified Master Dealer? Does applicant sell autos on consignment? Does applicant operate as an auto auction? Are all test drives accompanied by an employee? If "No," what percentage of test drives are unaccompanied: % Are overnight test drives allowed? Number of vehicles sold per month: Maximum radius of pick up & delivery: How do you transport autos? Owned truck/trailer Contracted tow truck or car hauler Driven by employees Temporary contract drivers Do you sell autos with salvage titles? If "Yes," please explain: Are you a Buy Here/Pay Here? If "Yes," when are titles transferred? If "Yes," are you listed as lienholder on the title? Customer Loaner Vehicles Does applicant provide customer loaner vehicles? If "Yes," which controls does the applicant have in place? Formal loaner agreement Copy of drivers license Verify personal auto insurance Page 6 of 7
Employee Sponsored Retirement Plans Does the insured sponsor a retirement plan (401K) or Pension Plan for their employees? If "Yes," what is the name of the plan? If "Yes," what are the current total assets of the plan? $ Non-dealer Operations (Complete approximate percentage for all operations.) Airbag installation, service, or repair: % Parking lots & garages (self park) % Alarm, stereo, or navigational system: % Parts sales (uninstalled): % Gross receipts: $ Auto dismantling/salvage yard: % Body shop: (answer questions below) % Parts/manufacturing/rebuilding: % Brake repair: % Car wash (full-service): % Convenience store: % Gross receipts: $ Detailing: % Driveaway contractor services: % Frame straightening: % Any frame cutting or welding? Gross receipts: $ Describe parts: Performing enhancements: % Any turbo or nitrous installation? Propane sales: % Is tank barricaded on all sides? Trained technician dispensing fuel? Tire dealer (complete supplement) % Fuel tank repair: % Towing (complete supplement) % Gasoline station (full-service): % Gallons of gas sold annually: Trailer hitch installation: % Transmission: % Ignition interlock systems: % Upholstery: % Impound yards: % Valet parking (complete supplement): % Lift/lowering kits: % Vehicle conversions (structural): % Machine shop (rebuilding): % Welding: % Mobile auto repair: % Window tinting: % Oil/lube services: % Windshield installation/repair: % Other (describe): % Paint and Body Shop Operations 1. Are all paint booths in operation NFPA compliant? 2. Are all paint booths in operation protected by an automatic sprinkler or dry chemical fire suppression system? 3. Are all paint mixing areas enclosed in a non-combustible enclosure with self-closing metal door? 4. Are all paint mixing areas equipped with explosion proof lighting and electrical? Please Provide the Following Information: Producer s Name: Applicant s Name: Date: Producer s Signature: Applicant s Signature: 182424-AAM-WEB-APP Page 7 of 7