Tell us about yourself
Date
Years in Business
If less than 3 years, years exp. in car business
Owners Name
Age
Married Yes No
Home Phone
Cell Phone
Ages of children living at home
Tell us about your business
Business Name
Business Address
Business Phone
Business City
Business State
Business County
Business Zip
Business Email
Ownership (check one) Individual Partnership Corporation *
Wholesale % *
Retail % *
Previous Insurance Carrier *
Expiration Date *
Any Losses (3 yrs) Yes No *
If yes, please describe
Please provide the number of each of the following:
Owners
Manager
Sale
Buyer
Detailer
Mechanic
Clerical
Finance
Drivers
Part-time Drivers
Any employees with violations or accidents in past 3 years?
If so, list employee and whether accident or violation
Any employee under 25 or over 50? Yes No
If so, list age and occupation:
Any owners, spouses or employees furnished with an auto? Yes No
If so, whom:
Number of Dealer Tags
Number of Registered Tags
Radius of Operation
Largest city traveled through
Do you have any towing vehicles, trailers or tow dollies Yes No
If so, which and what kind?
Do you conduct any other operations at your business Yes No
Do you hire pick up drivers? Yes No
If yes, how many?
Do you finance autos? Yes No
Do you repossess autos? Yes No
Do you lend vehicles? Yes No
Do you rent vehicles? Yes No
Do you lease vehicles? Yes No
Do you hire transporters Yes No
Do you have a dog on premises? Yes No
Do you sponsor racing vehicles? Yes No
Do you sell parts? Yes No
Do you engage in tire recapping? Yes No
Do you engage in auto dismantling? Yes No
Do you spray paint on premises? Yes No
Do you have an approved booth? Yes No
Is the lot fenced? Yes No
If not, how is the lot protected?
During open hours?
During closed hours?
Is the lot lit at night? Yes No
Do you photocopy driver license of customer Yes No
Do salesmen accompany customer on test drives? Yes No
Do you photocopy insurance ID cards? Yes No
Total Inventory amount (total value of all vehicles)
Average number of cars on lot
Average value of any car on lot
Maximum value per vehicle on lot
Deductible
(If no amount is specified, we will quote 50/100/25 limits for Garage Liability Insurance and 25/50/25 limits for Unisured Motroist Insurance)
Garage Liability (state minimum 50/100/25 can up to 1 million)
Uninsured Motorist (25/50/25 up to 1 million)
Medical Payments (500,000 up to 50,000,000
This is for any non owned vehicle (if for instance, you have a repair shop and you want to make sure to cover your customers vehicle or you consign vehicles)
GKLL Limit
Maxmimum value per one auto
We will need a copy of your Loss Runs from the past 3 years. You can get this information from your previous agent.
Comments
Thank you for your submission. A quote will be emailed to your address on the form.
Motor Vehicle Dealer Services6887 Oak Ridge Commerce WayAustell, GA 30168Phone: 770-941-0293Toll Free: 800-793-5177Fax: 770-941-5135Ron@RonWidener.com
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