/ Agency:
Producer:
Address:
Email:
Phone:
Ph: 912.450.7500 W: 888.554.8864 Fx: 912.450.7707 / Date:

AUTOMOBILE SERVICE/REPAIR, ROADSIDE SERVICE SUPPLEMENTAL APPLICATION

(ATTACH WITH ACORD APPLICATIONS AND OTHER SUPPLEMENTS THAT APPLY)

Applicant’s Legal Name:
Address:
Location 1:
Location 2:
Location 3:
Location 4:
Individual Corporation LLC
Partnership Joint Venture Other(describe)
Owners Name: / Effective Date:
Phone: / Fx: / Years in Bus:
Has applicant owned a similar business or had any change in ownership, management or name in the past 5 years?
Yes No If yes, please explain:
Is applicant a subsidiary of another entity or does the business have any subsidiaries? Yes No
If yes, explain:
AUTOMOBILE REPAIR SHOPS/MOBILE SERVICE/ROADSIDE SERVICE
Any Body work? Yes No / If body work is there a UL approved spray booth? Yes No
Any Frame Straightening? Yes No / Auto Dealer? Yes No
Any Trailer Hitch Installation? Yes No / Any work performed on high performance or racing autos? Yes No
Any auto rebuilding? Yes No / Own or sponsor a car for racing? Yes No
Any WeldingYes No / Storage Lot? Yes No
Repair Shop? Yes No / % of total Sales: How Many Bays? How Many Mechanics?
Mobile Repair Yes No / % of total Sales: How Many Service Employees?
Roadside Service Yes No / % of total Sales: How Many Service Employees?
Total Repair Sales:
Explain Roadside safety procedures for Roadside Service Customers:
Percentage of work:
Your Shop: / Customer’s Yard: / Truck & TravelCenter:
Roadside: / Other: Explain:
HEAVY VEHICLE SERVICE
IF NOT APPLICABLE CHECK HERE
Percentage of work:
Extra Heavy Trucks/Tractors: / RVs: / Buses:
Trailers: / Refrigerated Trailers: / Tank Trailers:
Emergency Vehicles: / Other: Explain:
Describe heavy vehicle operations in remarks

Remarks

Loss History

Insurance Company / Year / Premium / # of Losses / Amount Paid & Reserved
APPLICANT: I BELIEVE THE STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT. I UNDERSTAND THAT THE INSURER WILL RELY ON THESE STATEMENTS IF A POLICY IS ISSUED. I AGREE TO PROMPTLY REPORT ALL FULL TIME AND PART TIME DRIVERS. MY EMPLOYEES UNDERSTAND THAT MOTOR VEHICLE REPORTS WILL BE ORDERED ON THEIR BEHALF, I AUTHORIZE THE INSURER, AGENT, OR BROKER TO ORDER THESE REPORTS ON EACH DRIVER I EMPLOY OR CONTRACT. THIS APPLICATION ALONE DOES NOT BIND COVERAGE.
NOTICE OF INSURANCE INFORMATION PRACTICES
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, SUCHINFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCESBE DISCLOSED TO THIRD PARTIES. YOU HAVE TO RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTIONOF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPONREQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERTO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)
Applicant’s Signature Producer’s Signature
Date Date
REV 2-10-11