Garage Clients (Auto Repair) Form

AUTO SERVICE GENERAL QUESTIONNAIRE

Insured's Name: *

Years in industry/experience? *

Insured's Email *

Insured's Phone Number

Description of Operations (Check all that apply and provide annual sales information) *

Mechanical Repair - Annual Sales *

Body Shop - Annual Sales *

Salvage/Dismantling/Junkyard - Annual Sales *

Service Station - Annual Sales *

Convenience Store - Annual Sales *

Car Wash - Annual Sales *

Tire Dealer Sales/Service - Annual Sales *

If Other, Please Describe *

Hours of Operation

Or, 24 Hour Operation

Or, 24 Hour Operation

If 24 hours, number of employees/attendants on duty during late evening/early morning hours? *

Any vehicle sales? *

Yes
No

Any towing operations? *

Yes
No

If contracts are in place, please describe: *

Number of dealer / transporter plates? *

Identify the use of each: *

Who controls the use of the plates? *

Do non-employees have access to dealer plates? *

Yes
No

Garagekeepers Coverages

Coverage Type:

Comprehensive
Collision

Coverage Form

Direct Basis

Vehicles Covered

Symbol 30, coverage for customer-owned autos left with the garage for service, repair, storage, or safekeeping.

Enter The Total Comprehensive & Collision Coverage Limit For All Vehicles

(i.e. 10 Cars On Site Worth $50,000 each equals $500,000 Total Coverage Needed)

Average # Of Autos On Site

DEDUCTIBLE PER AUTO

MAXIMUM DED PER LOSS

Maximum # of autos kept on premises at one time?

Number of Service Bays?

Average value per auto kept on premises?

Vehicles loaned, rented or leased? *

Yes
No

If yes, give details:

Dog kept on the premises at any time? *

Yes
No

Insured subcontract any work? *

Yes
No

If yes, are certs. obtained? *

Yes
No

Work performed on vehicles used in racing? *

Yes
No

If yes, give details:

Work performed on classic/antique vehicles? *

Yes
No

If yes, give details:

Woodstoves or waste oil heaters utilized? *

Yes
No

Cutting/welding done on premises? *

Yes
No

If yes, describe operations and precautions taken to address "sparking"

Housekeeping and maintenance of the buildings and grounds adequate? *

Yes
No

Crime Exposures

Building alarmed with:

Burglar Alarm? *

Yes
No

Building Equiped with:

Video surveillance cameras? *

Yes
No

Robbery panic buttons? *

Yes
No

Is there a security/watchman service? *

Yes
No

Are there firearms on premises? *

Yes
No

Maximum amount of cash kept on premises:

At any one time? *

Overnight? *

Employee background checks made/reviewed? *

Yes
No

Cigarette/tobacco products sold? *

Yes
No

If Yes:

OPTIONAL SUPPLEMENTAL QUESTIONNAIRES

REPAIR GARAGE SUPPLEMENTAL (If Applicable)

Describe type(s) of repairs the insured does (e.g. tune-ups, major engine/transmission repair, etc.:

Describe (e.g. tuneups, major engine / transmission repair, etc.):

Any work performed on: (place a check in any of the following boxes if the exposures exists)

Describe

Any body work/spray painting?

Yes
No

If yes, to what extent?

All replacement parts new?

Yes
No

If not, advise where parts are obtained from:

UL approved parts cleaning cabinet with self-closing lid used?

Yes
No

Safety solvent use for parts cleaning?

Yes
No

If no, what product(s) is used?

Are garage tools/equipment etched with I.D. markings and/or serial numbers records kept?

Yes
No

SERVICE STATION/CONVENIENCE STORE SUPPLEMENTAL (If Applicable)

SERVICE STATION/CONVENIENCE STORE SUPPLEMENTAL

Full Service
Self Service
Combination Full/Self Service

Any convenience store operation?

Yes
No

Any alcoholic beverages sold?

Yes
No

If yes, is there separate Liquor Liability Insurance?

Yes
No

/ set does

Fire extinguishers kept within 100 feet of all tanks and pumps?

Yes
No

Liquid Petroleum Gas sold?

Yes
No

If yes, what % of total sales does LPG sales represent?

CAR WASH SUPPLEMENTAL (If Applicable)

CAR WASH SUPPLEMENTAL (If Applicable)

Auto
Manual

Attendant on premises at all times?

Yes
No

Are floors properly finished to prevent slips/falls?

Yes
No

For self-service washers, how often are consoles emptied of cash and deposits made?

BODY SHOP SUPPLEMENTAL (If Applicable)

Welding and cutting areas separated from other operations?

Yes
No

Spray painting done?

Yes
No

If yes, full body or incidental/touch up work?

Which of the following set ups apply to the spray paint area (check one)?

U.L. approved booth
Separate building
Cut off room
Other

If other, describe

Facility equipped with explosion proof electrical wiring and components?

Yes
No

UL approved ventilation system?

Yes
No

Portable extinguishers properly mounted, tagged and dated for inspection?

Yes
No

Smoking prohibited in repair, painting and storage areas?

Yes
No

Upholstery/convertible roof work performed?

Yes
No

TIRE DEALER SUPPLEMENTAL (If Applicable)

Is any Recapping or retreading performed?

Yes
No

Square footage of floor area dedicated to tire storage?

Any specialty tires sold? (e.g. Farm tractors, trucks, construction equipment, etc.)

Yes
No

If yes, explain

Cages used in the removal of tires other than passenger car or light truck tires?

Yes
No

Explain

Any used tire sales?

Yes
No

If yes, what % or total sales?

service@monteleoneins.com | 631-544-4000

AUTO SERVICE GENERAL QUESTIONNAIRE

Garagekeepers Coverages

Crime Exposures

OPTIONAL SUPPLEMENTAL QUESTIONNAIRES

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