Security Financial Insurance a member of Landmark Insurance Group 6501 E. Belleview Ave #550 Englewood, CO 80111 Ph. 720-922-7376 Garage Application ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT. Contact Name: Phone Number: Insured Name: Insured Website: Insured Address: Proposed Policy Period to Location #1 Location #2 ** List all additional locations on a separate sheet of paper. ** Individual Partnership Joint Venture Corporation Other Inspection and Audit Contact / Phone Number Years in business Description of Operations and Exposure NATURE OF BUSINESS Dealer: Wholesale Retail Non-Franchised Franchised with Non-Dealer: Repair Shop Gas Station Parking Facility Other UNDERWRITING INFORMATION DO YOU: YES NO 1. Engage in any other operations? 2. Sponsor sporting or social events? 3. Sponsor or own any race cars? 4. Sponsor driver s education cars? 5. Install, service or repair air bags? 6. Structurally alter or convert vehicles from their original design? 7. Allow test driving of vehicles unaccompanied? 8. Repossess vehicles for others? 9. Engage in fuel conversion? 10. Have guard dogs? 11. Operate petroleum or LPG trucks? 12. Engage in auto pawning? 13. Sell vehicles with salvaged titles? 14. Allow customers in the work area? 15. Rent, lease or load vehicles, machinery or equipment to others? YES NO Explain all YES responses:
PLEASE INDICATE THE PERCENTAGE OF YOUR INVOLVEMENT IN THE FOLLOWING TYPE OF AUTOS Sales Repair Private Passenger Type Including Light & Medium Trucks - New % % Private Passenger Type Including Light & Medium Trucks - Used % % Antique/Classic Cars % % Boats - Other than Jet Skis % % Jet Skis % % Busses % % Contractors Equipment % % Farm Equipment % % Emergency or Public Livery % % Heavy Truck (over 20,0000 GVW) **additional supplement required** % % Kit Cars or Other Manufacturing % % Motorcycles, ATVs, Scooters, Snowmobiles **additional supplement required** % % Mobile Homes % % Recreational Vehicles and Campers **additional supplement required** % % Semi Trailers **additional supplement required** % % Trailers - Other than Semi Trailers % % TOTAL 100% DEALER OPERATIONS Cosigned s Held for Sale % Owned Held for Sale % Auction % Wholesale s % Other: % Number of Dealer Tags: NON-DEALER OPERATIONS Alarm, Stereo or Navigational System % Maintenance or Repair Incl. Bed liner % Painting with UL approved spray booth % Painting without UL approved spray booth % Parts Sales Receipts: % Body Shop % % Car Wash - Full Service % Convenience Store Receipts: % Detailing % Drive away Contractor or Wrecker Service % Frame or Unibody Straightening % Gasoline Station - Full Service % Impound Yards % Mobile Repair % Oil/Lube Service % Parking Lots & Garages % Tire Dealers - New % Tire Dealers - Used, Retreads or Split Rims % Trailer Hitch Installation or Repair % Upholstery % Valet Parking **additional supplement required** % Van Conversion % Window Tinting % Windshield Installation/Repair % Other %
Owned s How are vehicles stored? Standard Lot* Non-Standard Lot* Maximum value any one? Maximum value of all s? Average number of s? VEHICLE STORAGE & VALUES Non-Owned s How are vehicles stored? Building Standard Lot* Building Unfenced Lot Non-Standard Lot* Unfenced Lot Maximum value any one? Maximum value of all s? Average number of s? Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent 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 the exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with openings securely locked when unattended. Non-Standard Lot: Any other type of protection or unprotected lots. Radius of Pickup & Delivery: None 0-300 Miles 301-500 Miles 501-1000 Miles +1000 Miles EMPLOYEE AND NON-EMPLOYEE INFORMATION YOU MUST COMPLETE THE FOLLOWING INFORMATION FOR ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS *Refer to the guides below for status, hours worked, and auto use. Name and Driver s License # & State Date of Birth Violations & Accidents Prior Three years Status Hours Worked Use STATUS: 3. Salesperson 9. Spouse of any other person furnished an auto 4. Lot Person 10. Children of any other person furnished an auto 5. Mechanic 11. Occasional or Contract Driver 6. Clerical 12. Other HOURS WORKED: F = Full Time (Over 20 hours per week) P = Part Time (20 or less hours per week) N =Non-Employee AUTO USE: A = Furnished a covered auto for personal use B = Uses a covered auto strictly for business use C = Does not drive a covered auto ADDITIONAL INFORMATION
Limit of Liability GARAGE LIABILITY: Other Than Other Than Aggregate Limit BI PD PERSONAL INJURY PROTECTION OR NO-FAULT COVERAGE: Per Statute MEDICAL PAYMENTS: Garage Operations UNINSURED MOTORISTS COVERAGE: UNDER INSURED MOTORISTS COVERAGE: GARAGE KEEPERS: Legal Direct Excess Direct Primary Limit of Coverage Limit Per Location Limit Per Other Than Collision Collision Comprehensive In-Tow Coverage Limit Per Tow Truck # of Tow Trucks DEALERS OPEN LOT: Comprehensive Limit of Coverage Limit Per Location Limit Per Other Than Collision Collision Additional Insured Waiver of Subrogation Name Address Insurable Interest Broadened Coverage (includes Personal Injury & $50,000 Fire Legal) Hired Fire Legal Liability Limit Personal Injury Liability ADDITIONAL COVERAGES: Truth In Lending E&O Federal Odometer Statute E&O Title E&P Insurance Agents E&O False Pretense
PRIOR CARRIER AND LOSS HISTORY List prior carrier and loss history for the past 3 years. If no losses, please indicate. Current Carrier Policy Period Policy Premium Prior Carrier Policy Period Policy Premium Prior Carrier Policy Period Policy Premium Date of Loss Amount paid/reserve Description of loss including driver If there is no prior insurance, check the box. NOTICE: The policy of insurance applied for does not provide coverage as required by Environmental Protection Agency (EPA) 40 CFR Parts 280 and 281 for underground storage tanks nor coverage under CERLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION. the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. This application shall not be be made, and then only as of the commencement date of said policy and in accordance with all term thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the insured. Witness Date Applicant s Signature