BERKSHIRE HATHAWAY HOMESTATE COMPANIES
SUPPLEMENTAL GARAGE APPLICATION
SECTION 1 - APPLICANT INFORMATION
Policy Period Requested: From:
/ /
To :
/ /
Applicant Info
Business Trade Name:
Mailing Address:
City:
State:
Zip:
Phone:
Internet Address:
Agency Info
Agency Name:
Mailing Address:
City:
State:
Zip:
Phone:
Contact Person:
SECTION 2 - SUMMARY OF OPERATIONS
Type of Garage Operation (Check all the apply)
Auto Dealer (Complete Section 3 of Application)
Garage Service and Repair (Complete Section 4 of Application)
Auto Salvage and Recycling (Complete Section 5 of Application)
Other Operations: Specify
Number of Years Business Experience:
Annual Revenue
If Less than 2 Years, describe prior experience:
Employee/Driver Info: (Include ALL family members whether they drive or not and check all boxes that apply)
Name
DOB
Drivers
Full-Time (F)
Auto
Service/
Office
Furnished
Family
License #
or
Sales
Repair/
Worker /
Vehicle
Member
Part-Time (P)
Salvage
Other
of Owner
Sales
Attach any additional employees as a separate schedule.
Total Number of Employees =
General Underwriting Questions:
1. Are there underground fuel/waste storage tanks of the premises?(If “yes” complete tank supplement)
2. Are there propane tanks on the premises?
3. Do you repossess vehicles?
4. Any rental/leasing/loaning of vehicles?
5. Are any other businesses that are not your own conducted from the same premises?
6. Does anyone live on the premises?
7. Are racing activities participated in or sponsored by the applicant?
8. Does applicant own or operate any vehicles not held for sale (ex. Tow Truck Service Vehicle, etc…)?
9. Does applicant sell salvaged vehicles? (if “Yes” provide details and how many)
10. Does applicant engage in any parking operations (pay for parking or valet)?
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
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11.
12.
13.
14.
15.
16.
Does applicant hold auctions on applicant premises?
Does applicant operation include a carwash?
Does applicant have any guard dogs on the premises? (if “Yes”, how many and what kind?)
Does applicant have any weapons on the premises? (if “Yes”, how many and what kind?)
Does the applicant engage in any off-site demolition or site removal and remediation?
Does the applicant share common ownership with any other businesses? (if “Yes”, provide details)
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
If answer to any question above is “Yes” please explain:
Lot Protection / Security (Check all that apply)
Chain Link Fence
Local Police Patrols
Chain/Cable & Post Fence
Fully Lit at Night
Central or Station Alarm
Security Guard or Watchman
Guard Dogs
Firearms on Premises
Other
SECTION 3 - AUTO DEALERS SECTION
If applicant does not engage in Auto Dealer operations, check box to right and skip the rest of this section
Total annual revenue from sale of vehicles (breakdown)
 New Vehicle Sales:
 Used Vehicle Sales:
 Salvaged Vehicle Sales:
Number of dealer plates
 Full Use:
 Demo:
 In-Transit:
Average value per car for sale:
Maximum value per car for sale:
Average number of cars for sale:
How many cars are currently for sale:
Average number of cars sold annually
 Current Year:
 Prior Year:
Maximum number of cars that can be kept
 On Lot:
 In Garage:
Indicate the percentage of business that is derived from the sale of:
Vehicle Type
% of Sales
Vehicle Type
Private Passenger Autos
Farm Equipment
Pickup Trucks & SUV’s
Motorcycles
Conversion Vans
Mopeds/ATVs
Truck Tractors
Snowmobiles
Trailers
Boats
Motor homes / RV’s
Golf Carts
Mobile Homes
Boats
Campers
Jet skis / Watercraft
Buses
Other (Specify)
Emergency Vehicles
Dealer Underwriting Questions:
1. Any operations other than 100% Retail Sales? (if “Yes” explain below)
2. Any wholesale vehicle sales operations?
3. Do you sell vehicles on a consignment basis? (if “Yes” indicate percentage below)
4. Do you sell salvaged vehicles? (if “Yes” indicate annual number and nature of vehicles)
5. Are autos transported by anyone other than listed employees? (if “Yes” explain below)
6. Does salesperson always accompany customers on test drives?
7. Are ignition keys locked in safe or taken home with owner at night?
8. Are ignition keys removed from vehicles when unattended?
9. Is public prohibited from service area with signs posted?
10. Any in-house financing on cars sold?
11. Is applicant located in a flood plain? (if “Yes” how far to closest body of water?)
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% of Sales
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
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Additional Detail/Explanation:
How are autos transported from purchase point to destination:
Method of Transport
Percentage
Subcontract with insured transport service
Pulled by tow bar
Towed/Hauled by owned units
Method of Transport
Driven by full-time employees
Driven by part-time employees
Other- specify
If travel > 50 Miles to pickup/deliver vehicles: # Trips 51 – 200 miles:
Percentage
# Trips 200+ Miles:
SECTION 4 – GARAGE SERVICE AND REPAIR
If applicant does not engage in Garage Service operations, check box to right and skip the rest of this section
Revenue Breakdown (non-dealer): Service/Repair Revenue:
What percentage of your work is:
Operation
%
Alarm System Installation
Auto Accessories Installation
Auto Detailing
Auto Glass Repair
Operation
Auto/Van/SUV Conversion
Emissions Testing
Stereo/Sound Installation
Bus Repair (Mechanical)
Emergency Vehicle Service &
Repair
Fire Engine Service & Repair
Heavy Truck Body Repair
Heavy Truck Mobile Repair
Heavy Truck Repair
(mechanical)
Heavy Truck Major Engine
Repair
Airbag Repair and Installation
Auto Repair (light truck and
PPT)
Boat Engine Repair (land based)
Body Work (light truck and PPT)
Brake Repair (light truck and
PPT)
Carburetor Install/Repair
Collision Repair (light truck and
PPT)
Emergency Roadside Service
Impound Yards (w/ Towing
Only)
Major Engine Repair (light truck
and PPT)
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%
Muffler Repair and Installation
Radiator Repair and
Installation
Tire Repair
Trailer Skin Work
Bed Liner Installation (nonspray)
Clear Coating (No body work)
Custom Painting (No body work)
Other Electronics Installation
Hail & Dent Repair
Air Conditioning Service
Antique/Classic Auto Restoration
Retail/Sales/Parts Revenue:
Auto Dismantling
Bus Repair (Collision)
Alcohol Detection Device
Installation
Construction Equipment
(Wheel based)
Construction Equipment
(other)
Farm Equipment Repair
Frame Straightening
Logging Equipment Repair
Motorcycle Repair
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Operation
%
Trailer Hitch Repair/Installation
Refrigeration Trailer Repair
RV Repair – Exterior/Interior
RV Repair –
Mechanical/Electrical
Boom/Crane Repair
Cherry Picker Repair
Handicap Lift Installation &
Repair
Heavy Truck Conversions
Hydraulic Repair
Trailer Conversions
Trailer Repair
ATV Service and Repair
Forklift Repair
Jet ski/Snowmobile Service &
Repair
Kingpin or 5th Wheel Installation
& Repair
Lawn/Garden Equipment
Installation & Repair
Auto Reconstruction and
Rebuilding
Misc. Equipment Repair (nonwheel based)
Oil & Lube (light truck and PPT)
Machining, Metal Fabrication, and
Manufacturing
Tanker Trailer or Fuel Trailer
Repair
Other (Specify):
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Underwriting Questions:
1. Does the applicant perform any welding?
2. Are the applicant’s employees ASE certified mechanics?
3. Does the applicant sell or install:
New Tires
%
Used Tires
4. Does the applicant conduct FMSCA annual vehicle safety inspections?
5. Does applicant only have UL approved paint booth (for painting)?
6. Can the public use the repair facility to perform their own repairs?
Yes
Yes
%
Yes
Yes
Yes
No
No
Re-capped Tires
%
No
No
N/A (no painting)
No
SECTION 5 – AUTO SALVAGE AND RECYCLING OPERATIONS
If applicant does not engage in Auto Salvage operations, check box to right and skip the rest of this section
Underwriting Questions:
1. Is the yard completely fenced on all sides?
Yes
2. Does the operation stack autos more than three vehicles high?
Yes
3. Can the public use the facility to perform their own repairs?
Yes
4. Do customers have access to the yard?
Yes–Accompanied
Yes–Unaccompanied
5. Can customers pull their own parts?
Yes
6. Does the operation own a car crusher?
Yes
7. Does the operation have a computerized inventory system?
Yes
8. Does the operation rebuild parts or vehicles? (if Yes, provide detail including number each year)
Yes
9. Does the operation deal in scrap other than autos? (if Yes, provide detail)
Yes
10. Does the operation recycle tires? (If “Yes” provide details on quantify of tires stored)
Yes
11. Does the operation haul crushed vehicles?
Yes
12. Does the operation dispose of gas tanks, batteries, waste fuels, and oils? (If “Yes” describe how)
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Additional Detail:
Yard Information:
Acreage:
Average Number of Vehicles in Yard:
Fence Height:
Fence Construction:
Does any one live on the premises?
Yes
If “Yes” who lives there:
No
Describe Adjacent Exposures to Yard:
SECTION 6 – TOWING COVERAGE
If applicant does not engage in Towing operations, check box to right and skip the rest of this section
On Hook Limits: $
Per Unit Limit. $
Per Unit Deductible Max # of Units Hauled at one time:
* If Limit varies per vehicle, please attach schedule and note “see schedule” above
Breakdown of Towing Activities:
Type of Towing
Involuntary Repossession
Voluntary Repossession
Truck-Tractors
Roadside Assistance / AAA
Other Towing
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Percentage of Towing Operations
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SECTION 7 – MINIMUM INFORMATION REQUIRED TO FURNISH QUOTE
A. ACORD 125 and ACORD 128 Application.
B. ACORD 129 Application for any vehicles not held for sale.
C. Currently valued insurance company loss runs for the present and prior 2 years. For accounts with more than 20
employees, loss runs are required for the present and prior 4 years.
D. Complete employee/driver list, showing full name, date of birth, and drivers license number.
E. For accounts with more than 20 employees: Current annual financial statement – including profit & loss, balance
sheet & cash flow.
SECTION 8 – DISCLOSURE AND SIGNATURES
The company is relying upon the statements and representations made by the applicant or the agent in this application in determining
whether to issue a policy of insurance with the coverages requested by the applicant. The company considers these statements and
representations to be material to the risk or hazard to be assumed by the company. It is understood and agreed that this application,
and the statements and representations made herein, shall be and hereby are incorporated into and made a part of the policy issued to
the applicant by the company. If either the applicant or agent fails to disclose materials factors or provides false information, it may
result in the company denying coverage or rescinding the policy.
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime and will subject the person to criminal and (NY:
Substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; In DC, LA, ME, TN, VA, and WA, insurance
benefits may also be denied)
This document is to serve as an application only and is NOT A BINDER OF INSURANCE.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the
answers to questions on this application. He/She certifies that the answers are true, correct, and complete to the best of his/her
knowledge.
_______________________________
Producer Signature
________________________________
Applicant Signature
_______________________________
Today’s Date
________________________________
Today’s Date
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