Klein & Costa Insurance Services
200 E. Sandpointe Avenue, Suite 310, Santa Ana, CA 92707
Garage Liability / Garagekeepers Application
Retail Agency Name:
Location:
Phone:
Applicant General Information
Effective Date:
Expiration Date:
Applicant Name:
Mailing Address:
Phone:
Years In Business:
Business Entity Type:
Inspection Contact:
Years Of Experience:
Individual
Partnership
Corporation
Other:
Website Address:
Full Description if Operations and Exposures:
Garage Location #1:
Garage Location #2:
Garage Location #3:
Underwriting Information
1. Do you engage in other operations?
If Yes, Please Explain:
Yes
No
2. Do you structurally alter / convert vehicles from their original design?
If Yes, Please Explain:
3. Do you repossess vehicles for yourself or others?
If Yes, Please Explain:
Yes
No
Yes
No
4. Do you allow customers in the work area?
If Yes, Please Explain:
5. Do you pick up or deliver customer vehicles?
If Yes, Please Explain:
Yes
Yes
No
No
Types Of Vehicles
Sales:
Repair:
%
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%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
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Private Passenger Autos, Pickups, Vans, SUV’s (New)
Private Passenger Autos, Pickups, Vans, SUV’s (Used)
Antique or Classic Autos
RV’s, Motor Homes, Campers (Supplement Required)
Heavy Trucks / Semi Trailers (Supplement Required)
Motorcycles / ATV’s / Scooters (Supplement Required)
Boats
Jet Skis
Golf Carts – Licensed For Road Use:
Yes
No
Mobile Homes
Contractor’s Equipment
Farm Equipment
Emergency Vehicles – List Types:
Kit Cars
Buses
Trailers Other Than Semi Trailers – List Types (i.e., Horse,
Utility, Other – Describe):
Other – Explain:
%
%
TOTALS
Dealer Operations
Provide Breakdown of Operations:
% Consigned Auto Sales
% Retail Auto Sales
% Other – Explain:
% Wholesale Auto Sales
% Owned Autos Left At Auction
Maximum Radius of Pickup and Delivery:
0-300 Miles
301-500 Miles
501-1,000 Miles
Over 1,000 Miles
Non-Dealer Operations
% Alarm, Stereo, Navigational System
% Auto Dismantling
% Auto Maintenance and Repair (Including Bedliners)
% Auto Painting – With UL Approved Spray Booth
% Auto Painting – Without UL Approved Spray Booth
% Auto Parts – Uninstalled – Receipts: $
% Body Shop
% Butane / Propane / Other Liquefied Gas Sales
% Car Wash – Full Service
% Convenience Store – Receipts: $
% Detailing
% Driveaway Contractor or Wrecker Service
% Frame or Unibody Straightening
% Gasoline Station – Full Service
% Gasoline Station – Self Service
% Impound Yards
% Mobile Auto Repair
% Oil / Lube Service
% Parking Lots and Garages – Self Park
% Tire Dealers – New
% Tire Delaers – Used / Retreads
% Trailer Hitch Installation / Repair
% Upholstery
% Valet Parking (Supplement Required)
% Van Conversion
% Window Tinting
% Windshield Installation / Repair
% Other – Explain:
Vehicle Storage and Values
Owned Autos – Dealers Open Lot (See Lot Definitions Below)
Standard Lot*
Nonstandard Lot**
Building***
Unprotected Lot****
$
Maximum Value Of Any One Auto
Maximum Number Of Autos
Non-Owned Autos / Garagekeepers Liability (See Lot Definitions Below)
Standard Lot*
Nonstandard Lot**
Building***
Unprotected Lot****
$
Maximum Value Of Any One Auto
Maximum Number Of Autos
Lot Protection – Definitions:
*Standard Lot = open parking storage lots enclosed on all sides by metal cyclone or
equivalent fence not less than six feet in height; or, bounded on one or more sides by the
walls or wall of a building with no unprotected openings.
**Non-Standard Lot = any other type of protection or fencing – typically lots that are all
other open lot locations, or unroofed space and buildings not securely enclosed and
locked when unattended.
***Building = secured and locked building.
****Unprotected Lot = all others
Employee List
Employee / Non-Employee Schedule – Include All Owners, Spouses, Employees and
Non-Employees
1. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
2. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
3. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
4. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
5. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
6. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
7. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
8. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
9. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
10. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
11. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
12. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
13. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
14. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
15. Name:
Date of Birth:
State of License:
Driver License Number:
Number of Moving Violations and Accidents Past 3 Years:
Accidents
Citations
Job Description or Relationship:
Furnished Auto:
Yes
No
Exclude From Driving:
Yes
No
Hours Worked Per Week:
Hours
Specifically Described Autos
1. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
2. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
3. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
4. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
5. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
6. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
7. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
8. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
9. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
10. Year:
Make:
Model:
Vehicle Identification Number:
Titled In Business Name:
Yes
No
Used For Towing:
Yes
No
Gross Vehicle Weight:
Lbs
Use:
Radius Of Operations:
Loss Payee:
Coverages Desired:
Liability
Comprehensive / Collision
Uninsured Motorists
Personal Injury Protection
Actual Cash Value: $
Coverages and Limits Requested
$
Garage Liability:
Each Accident $
Aggregate $
Deductible
Garagekeepers:
$
Limit Per Location $
Limit Per Auto $
Deductible
Coverage:
Legal Liability
Direct Excess
Direct Primary
Specified Causes of Loss
Comprehensive
Collision
Dealers Open Lot:
$
Limit Per Location $
Coverage:
Specified Causes of Loss
Medical Payments:
$
Auto
$
Limit Per Auto $
Comprehensive
Deductible
Collision
Garage Operations
$
Uninsured Motorists / Underinsured Motorists:
Per Accident
Number of Dealer Tags
$
Personal Injury Protection:
Per Statute
Number of Dealer Tags
Broadened Coverages – Garage Liability (Adds Personal Injury and $50,000 Fire
Damage Legal Liability)
Fire Damage Legal Liability: $
Hired Auto Liability
Limit
Additional Insured:
Name:
Address:
Insurable Interest:
Waiver of Subrogation (For Owner Of Premises)
Prior Carrier / Loss History – Past 3 Years
1st Prior Year:
Carrier:
Policy Term:
Policy Premium:
Dates and Description of Losses – Including Amounts Paid and Reserved:
2nd Prior Year:
Carrier:
Policy Term:
Policy Premium:
Dates and Description of Losses – Including Amounts Paid and Reserved:
3rd Prior Year:
Carrier:
Policy Term:
Policy Premium:
Dates and Description of Losses – Including Amounts Paid and Reserved:
Additional Information:
Signature of Applicant: ______________________________________
Date: ______