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Garage Owners Quote
Form: Garage Owners Quote Request
Garage Owners Quote Request




Contact Information
First Name:
Last Name:
Daytime Telephone:
Evening Telephone:
Email:
Address:
City:
State:
Zip:
Years In Business:
Years Sales/Repair Experience:
Business Entity:
Individual
Partnership
Corporation
Describe your Operations:
Locations where you conduct Garage Operations
Location 1:
Location 2:
Underwritting Information List of Drivers
(Owners, Employees, Family)
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Name
Drivers License State of License:
Date of Birth Furnished Auto:
YES NO
Job Description and / or Relation: Past 3 Years Number of:
Accidents :
Citations:
Sales
Where do you purchase vehicles?
Who drives or tows vehicles to your lot?
How many times per year do you drive-away more
than 300 miles from point of purchase?
How many vehicles do you sell per year?
How many of those are on consignment?
What is your normal radius of operation?
What is your sales mix?
a. cars, sport utility, pickups, vans
%
d. trucks, tractors, semi-trailers
%
b. motor homes % e. salvage parts %
c. travel trailers, camp trailers
%
f. other
%
Describe your theft barriers (fence & gate or post & cable)
Describe your key controls
How many dealer plates do you have?
Do you repossess vehicles? YES NO
If yes, explain
Do you sell "salvage titled" vehicles? YES NO
If yes, what percentage of vehicles require:
% cosmetic repair
% mechanical repair
% structural repair
Do you always ride along on test drives? YES NO
Services
What percentage of your work is:
Body/Paint % Muffler %
Tune Up % Radiator %
Transmission % Wheel Alignment %
Brakes % Oil & Lube %
Sound System
%
Window Tint
%
Tires % Upholstery %
Wash/Detail
%
Other
%
Describe:
Do you sell gasoline: YES NO
or LPG: YES NO
If yes, how many gallons:
Do you install trailer hitches? YES NO
Do you have a spray paint booth? YES NO
If yes, is it U/L approved? YES NO
Is it ventilated? YES NO
Do you recap tires or sell recapped tires? YES NO
Do you tow for hire? YES NO
If yes, explain
Describe lot security and key controls
Prior Carrier and Loss History for 3 Years
Current Carrier:
Policy Period:
Policy Premium:
Prior Carrier:
Policy Period:
Policy Premium:
Prior Carrier:
Policy Period:
Policy Premium:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Coverage Requested
Garage Liability
$
Each accident $
Aggregate, Deductible
$
(Legal Liab.) Garage-keepers
$ per location
SCL $ deductible
Collision
$ deductible
Dealers Physical Damage
$ per location
SCL $ deductible
Collision
$ deductible
Type:
New
Used
Interests Covered:
Owner
Owner and Creditor
Consignment Owner
Premises Medical Payments $1,000
Specifically Described Autos:
Veh.No. Year Make
Body Type
ACV
V.I.N.
Veh.No. Year Make
Body Type
ACV
V.I.N.
Veh.No. Year Make
Body Type
ACV
V.I.N.
Veh.No. GVW Radius
Use
Loss Payee
Veh.No. GVW Radius
Use
Loss Payee
Veh.No. GVW Radius
Use
Loss Payee
Uninsured Motorist: $
Personal Injury Protection: $
Fire Legal Liability: $ 50,000
Buy-backs:
GK Transit Limit: $
Drive-Away Miles: $
Value per Auto: $
Remarks:
Comments or Questions
Deliver quote via:
 E-Mail Fax Regular Mail Telephone
No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

By completing this form, you are acknowledging your understanding of and agreement with these terms


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    Kupiec Insurance Group
    15 Brintons Bridge Road, Suite 100
    West Chester, PA 19382

    Office: (610) 526-1853
    Fax: (484) 631-1320
     

    © Kupiec Insurance Group, 2012


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