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Garage Liability Insurance Insured's Name Phone Number Fax Number Email Address Insured is: Please Choose Individual Partnership Corporation Joint Venture Business Name Street Address City Zip Code CA Class of Business & Gross Receipts TOTAL Gross Receipts: ATV Repair % Auto Alarm Installation % Auto Stereo Installation % Auto Body Shop % Auto Detailing Shop % Auto Repair Shop % Boat Repair % Bus Repair % RV Repair % Motorcycle Repair % Truck Repair % Car Wash Automatic % Car Wash self-Serve % Gasoline Station-Self % Gasoline Station-Full % Number of Gallons pumped last year: Gallons Quick Lube Shops % Snowmobile % Tow Truck Operations % Valet Services % Van Conversion Shop % Other % Years in this Type of Business Current Total Gross Receipts Number of Employees Total Payroll Complete the following if you require physical damage coverage for either your own or customer's vehicles: Vehicles are kept: Inside: % , Outside % Describe the protection (type of fence, lighting, police protection): If vehicles are kept inside: Age of building Construction Number of Floors Are ignition keys left inside the cars? Yes , No If vehicles keys are kept outside, where are they kept? Are cars locked when stored after hours? Yes , No Number of plates held by the Applicant: Dealer Repairer Transporter Loaner Other Coverages Desired: Garagekeepers Legal Liability Direct Primary Maximum value of all vehicles in your care, custody and control: Comprehensive OR Specified Perils Deductible per Vehicle Maximum deductible one loss Collision deductible On-hook coverage deductible Limit per Vehicle Tow Truck / Carrier / Scheduled Vehicles Comprehensive OR Specified Perils, Deductible Collision deductible Building: Including EE Yes , No Amount of Insurance Percentage of Value Deductible Personal Property of Insured Including EE Yes , No Amount of Insurance Percentage of Value Deductible Business income Including EE Yes , No Amount of Insurance Percentage of Value Deductible Loss History   Prior carrier and loss history for the past three years From Mo. Yr. To Mo. Yr. Company Name Policy number Cancelled or Non-renewed No Yes Reason If you have already been given a quote, entering the figure here may help you get a better deal

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