Service Station 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?
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:
6. Describe all adjoining or adjacent occupancies and/or vacancies:
7. Total annual gross sales by category:
Tire sales/service: $ Oil/quick lubrication work: $
Brake work: $ Towing: $
Other repair work: $ Body work: $
Gasoline/diesel sales: $ LPG sales: $
Mini-mart/grocery operations: $ Self-serve car wash operations: $
Full-serve car wash operations: $ Restaurant operations: $
Other: $ Explain:
8.a. No. of FULL-TIME workers (Include active owners, officers, partners, managers, mechanics,
clerical and subcontractors. Each active owner, officer or partner equals one full-time worker):
Car wash operations:
Mechanical or body work:
All other operations:
8.b. No.of PART-TIME workers (Include managers, mechanics, clerical and subcontractors):
Car wash operations:
Mechanical or body work:
All other operations:
9. Total area: square feet
Mini-mart/grocery customer area: square feet
Restaurant customer area: square feet
Car wash area: square feet
10. No. of gasoline/diesel pumps:
No. of self-serve car wash bays:
11. Parking area or number of spaces:
12. Building age: years
Date and extent of remodeling:
13. Any remodeling or building construction work to be performed during the policy period:
Yes No     If yes, explain:
14. Construction type: Frame Other
15. Electrical system protected by: Fuses Circuit breakers If fuses, indicate amperage:
16. Fire station within 5 miles: Yes No
Fire hydrant within 1,000 feet: Yes No
17. Fire extinguishers: Yes No
Sprinklers: Yes No
Smoke detectors: Yes No
18. Fire alarm: Local Central station None
Burglar alarm: Local Central station None
19. Name of alarm company:
Phone number:
20. Current and valid licenses as required by law:
21. No. of vehicles kept overnight:
Where are vehicles stored overnight:
22. Perform mechanical repair/service on large commercial trucks, buses, motor homes,
trailers, tractors, motorcycles, watercraft or other recreational vehicles: Yes No
23. Perform mechanical repairs/service or sponsor performance vehicles or vehicles used for racing
or stunting: Yes No
24. Perform mechanical repairs/service on high value or exotic cars: Yes No
25. Tow commercial vehicles/heavy equipment: Yes No
Tow under contract: Yes No
Note: If yes, provide proof of insurance
26. Rent/lease vehicles or equipment to others: Yes No
27. Offer "Rent-A-Bay" or other self-serve facilities: Yes No
28. Perform dismantling/wrecking/salvaging: Yes No
29. Perform new or used car sales:
30. Sell used or salvaged parts: Yes No N/A
If yes, are parts rebuilt by someone other than the applicant:
31. Perform mobile repair work: Yes No
32. Manufacture any components or parts: Yes No If yes explain:
Contract with others to manufacture components or parts for use or sale:
33. Liquor violations/citations in the past three years: Yes No N/A
If yes, explain:
34. Automatic fire suppression equipment over cooking surfaces and exhaust flue: Yes No  N/A
34.a.. How often are flues cleaned by a professional service:
34.b. High temperature limit cut-off switches on all deep fat fryers and ovens: Yes No N/A
34.c. Days of operation:
Business hours:
35. Describe all unusual operations or business practices not customary to this type of business:
36.. 4-year policy history (Company/Pol.#/Dates)
37. Loss history for the past 4 years: (include claims reported, unreported, and known occurrences which may result in claims): Description Date Amount Open/Closed
38. Has applicant had a fire loss at this or other property or business within 20 years: Yes No
If yes, describe:
39. Is the subject risk currently insured for both Property and Liability? Yes No
If yes, describe:
40. Any prior coverage declined, cancelled, or non-renewed in the past 3 years: Yes No
If yes, explain:
41. Has applicant seen risk/property in last 60 days: Yes No
Overall condition:
42. In the past six months, was property bank owned, in receivership, involved in bankruptcy proceedings or foreclosure:
43. Does applicant own any other income property or business: Yes No
Note: If yes, please explain:
44. 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:

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.