Untitled Document

CGA Auto Body Repair/ Garage Insurance Quote Request
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

Application Information Section

Name:
Business Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

Property Information Section

Property Address:
Property City:	State: ZIP:
Property County:
Total Square Footage of the Building Your Business is in:
Square Footage of your Business Only:
How many stories is this building?
Construction Type:
Roof Type:
Has the roof been Updated:
If yes, Year Roof was Updated:
Protection Distance:
Is the business in a brush area?
Is there storage more than 1500 sq. ft?
Are there smoke detectors at this location?
Smoke Alarms?
Theft Alarm?
Fire Alarm?
Fire Extinguisher?
Deadbolts on all Doors?
Circuit Breakers?
Electrical updated?
Heating - Air Conditioning, Thermostatically Controlled?
Heating - Air Conditioning, Central?
Plumbing Updated?
If yes, year plumbing was updated:
Interior Automatic Fire Sprinklers:
Is the parking lot under construction?

Underwriting Information Section

Please describe the nature of your business:
Number of Owners:
Number of Employees:
Number of Employees that work on vehicle:
Payroll of Owners:
Payroll of Employees:
Total annual gross receipts:
Total annual sub costs:
Business license number:
Bureau auto repair number (if different):
License Type:
Years of Experience:
How many years have you operated under your current business name?
Have you used any other business names during the past 5 years?	Yes No
Any work done on Commercial, Antique, Classic Cars?	Yes No
Number of vehicles kept overnight::
Where are the vehicles stored overnight?
How are the keys secured?
Do you loan cars out during repairs?	Yes No
Number of pickup or vehicle deliveries per day:
Average distance one way to pickup or delivery:
Selling or consignment of vehicles?	Yes No
Average number of vehicle stored overnight?:
Any LPG sales?	Yes No
Do you have a safety program in place?	Yes No
Do you test drive the repaired vehicles?	Yes No
If yes, do you check the driving record of those driving?	Yes No
Do you do any spray painting?	Yes No
If yes, is it in a UL approved booth?	Yes No
How many cars do you paint a week?
Average vehicle value stored overnight?
Average TOTAL value of all vehicles stored overnight?

Loss History Information:

Current Insurance Company:
Current Premium:
Prior Coverage ever been declined?
Ever file bankruptcy?
Losses claims in the last 5 years:
If yes, date, amount paid and description of each loss claim:

Coverage Section (Limits Profile):

Building Limit Requested:
Office Contents Limit Requested:
Shop Contents Limit Requested:
Loss of Rents Limit Requested:
Auto liability limit requested while test driving:
Maximum per vehicle damage (collision) loss limit while test driving:
Maximum per vehicle damage (comp) loss limit while the customer's vehicle is parked at your location:
Liability limits requested:
Any additional comments: