Auto Supply Store Insurance Application Form
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Name of Applicant and Mailing Address:
Property Address if different from mailing address:
Contact Number:                   Email:
1. Business entity: Individual Joint venture Partnership Corporation Limited Liab. Co.
Other:
2. Completely describe the operations at this location, including the number of
buildings and the number of units per building:
3. How long has applicant been in this type of business:
4. How long has applicant been at this location:
5. Is any portion of the applicant's premises subleased: Yes No
If yes, describe occupancy(ies) and related square footage:
Note: If yes, fax a copy of the lease to 619-444-5599.
6. Describe all adjoining or adjacent occupancies and/or vacancies:
7. Is location on a pier, dock, or waterfront: Yes No
8. Annual gross receipts: $
9. Total area:
Total customer area:
10. Parking area or number of spaces:
11. Building age: Years
Date and extent of remodeling:
12. Any remodeling or building construction work to be performed during the policy period: Yes No
If yes, explain:
13. Number of floors:
14. Construction type: Frame other
15. Plate glass (linear feet):
16. Electrical system protected by: Fuses Circuit breakers
If fuses indicate amperage:
17. Fire protection classification (NBC):
18. Properly functioning fire extinguishers: Yes No
Properly functioning sprinklers: Yes No
Properly functioning smoke detectors: Yes No
19. Fire alarm: Local Central station None
Burglar alarm: Local Central station None
21. Any direct importing: Yes No
If yes, describe:
22. Rental of any parts, equipment, or tools: Yes No
If yes, describe:
23. Any pick-up or delivery service: Yes No
If yes, describe:
24. Performance or subcontracting of any type of automotive repairs or installations: Yes No
If yes, describe:
25. Reconditioning or remanufacturing of any automotive part: Yes No
If yes, describe:
26. Sale of any used, reconditioned, or remanufactured automotive part: Yes No
If yes, describe:
26a. Sale of any items under the applicant's own label: Yes No
If yes, describe:
27. Has the applicant been charged with any violations by any regulatory body within the last three years:
Yes No
If yes, explain:
28. Describe all unusual operations or business practices not customary to this type
of business:
29. 4-year policy history (Company/Pol.#/Dates)
30. Loss history for the past 4 years: (include claims reported, unreported, and known occurrences which may result in claims): Description Date Amount Open/Closed
31. Has applicant had a fire loss at this or other property or business within 20 years: Yes No
If yes, describe:
32. Is the subject risk currently insured for both Property and Liability? Yes No
If yes, describe:
33. Any prior coverage declined, cancelled, or non-renewed in the past 3 years: Yes No
If yes, explain:
34. Has applicant seen risk/property in last 60 days: Yes No
Overall condition:
35. In the past six months, was property bank owned, in receivership, involved in bankruptcy proceedings or foreclosure:
36. Does applicant own any other income property or business: Yes No
Note: If yes, please explain:
37. List Any Lend holders- Name and Address:

Requested Coverages- Click here if you don't know

Building Coverage $ (Usually $75-100 a Square foot)
Personal Property Coverage $  
Loss of earnings coverage $  
Loss of rent coverage $  
Liability Coverage
Recommended 1 million per occ/ 2 million agg
 Per Occurrence$ Aggregate Limit $
Optional Crime Coverage- Contents burglary coverage $  
Optional Crime Coverage- Robbery (inside/outside coverage) $  

Additional Comments:

Referred by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.