USGInsurance Services, Inc.

www.usgins.com

Garage ApplicationALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT.

Broker: USG Insurance Services, Inc. Retailer:

Location:Contact Name:

Phone Number:

Insured Name:

Proposed Policy Period to

Location #1

Location #2

** List all additional locations on a separate sheet of paper. **

Individual Partnership Joint Venture Corporation Other

Inspection and Audit Contact / Phone Number

Years in business

Description of Operations and Exposure

NATURE OF BUSINESS

Dealer: Wholesale Retail Non-Franchised Franchised with

Non-Dealer: Repair Shop Gas Station Parking Facility Other

UNDERWRITING INFORMATION

DO YOU: YES NO1. Engage in any other operations?2. Sponsor sporting or social events?3. Sponsor or own any race cars?4. Sponsor driver’s education cars?5. Install, service or repair air bags?6. Structurally alter or convert vehicles from their original design?7. Allow test driving of vehicles unaccompanied?

YES NO8. Repossess vehicles for others?9. Engage in fuel conversion?10. Have guard dogs?11. Operate petroleum or LPG trucks?12. Engage in auto pawning?13. Sell vehicles with salvaged titles?14. Allow customers in the work area?15. Rent, lease or load vehicles, machinery or equipment to others?

Explain all “YES” responses:

Insured Website:

Insured Address:

PLEASE INDICATE THE PERCENTAGE OF YOUR INVOLVEMENT IN THE FOLLOWING TYPE OF AUTOSSales Repair

Private Passenger Type Including Light & Medium Trucks - New % %

Private Passenger Type Including Light & Medium Trucks - Used % %Antique/Classic Cars % %

Boats - Other than Jet Skis % %Jet Skis % %Busses % %

Contractors Equipment % %Farm Equipment % %Emergency or Public Livery % %Heavy Truck (over 20,0000 GVW) **additional supplement required** % %Kit Cars or Other Auto Manufacturing % %Motorcycles, ATVs, Scooters, Snowmobiles **additional supplement required** % %Mobile Homes % %

Recreational Vehicles and Campers **additional supplement required** % %Semi Trailers **additional supplement required** % %

Trailers - Other than Semi Trailers % % TOTAL 100%

DEALER OPERATIONS

Cosigned Autos Held for Sale %Owned Auto Held for Sale %Auto Auction %Wholesale Autos %Other: %

Number of Dealer Tags:

NON-DEALER OPERATIONS

Alarm, Stereo or Navigational System %

Auto Maintenance or Repair Incl. Bed liner %

Auto Painting with UL approved spray booth %

Auto Painting without UL approved spray booth %

Auto Parts Sales Receipts: %

Body Shop %

%

Car Wash - Full Service %

Convenience Store Receipts: %

Detailing %

Drive away Contractor or Wrecker Service %

Frame or Unibody Straightening %

Gasoline Station - Full Service %

Impound Yards %

Mobile Auto Repair %

Oil/Lube Service %

Parking Lots & Garages %

Tire Dealers - New %

Tire Dealers - Used, Retreads or Split Rims %

Trailer Hitch Installation or Repair %

Upholstery %

Valet Parking **additional supplement required** %

Van Conversion %

Window Tinting %

Windshield Installation/Repair %

Other %

VEHICLE STORAGE & VALUES

Owned AutosHow are vehicles stored?

Standard Lot* BuildingNon-Standard Lot* Unfenced Lot

Maximum value any one Auto?Maximum value of all Autos?Average number of Autos?

Non-Owned AutosHow are vehicles stored?

Standard Lot* BuildingNon-Standard Lot* Unfenced Lot

Maximum value any one Auto?Maximum value of all Autos?Average number of Autos?

Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet in height; or bounded on one or more sides by the wall or walls of a building, with no unprotected opening, and with the exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with openings securely locked when unattended. Non-Standard Lot: Any other type of protection or unprotected lots.

Radius of Pickup & Delivery: None 0-300 Miles 301-500 Miles 501-1000 Miles +1000 Miles

EMPLOYEE AND NON-EMPLOYEE INFORMATION

YOU MUST COMPLETE THE FOLLOWING INFORMATION FOR ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS

*Refer to the guides below for “status,” “hours worked,” and “auto use”.

Name and Driver’s License # & State

Date of Birth Violations & Accidents Prior Three years

Status HoursWorked

Auto Use

STATUS:

3. Salesperson 9. Spouse of any other person furnished an auto4. Lot Person 10. Children of any other person furnished an auto5. Mechanic 11. Occasional or Contract Driver6. Clerical 12. Other

HOURS WORKED: F = Full Time (Over 20 hours per week) P = Part Time (20 or less hours per week) N =Non-Employee

AUTO USE:A = Furnished a covered auto for personal useB = Uses a covered auto strictly for business useC = Does not drive a covered auto

ADDITIONAL INFORMATION

GARAGE LIABILITY:

Limit of Liability Deductible

Auto Each AccidentOther Than Auto Each AccidentOther Than Auto Aggregate Limit

BIPD

PERSONAL INJURY PROTECTION OR NO-FAULT COVERAGE: Per Statute

MEDICAL PAYMENTS: AutoGarage Operations

UNINSURED MOTORISTS COVERAGE:UNDER INSURED MOTORISTS COVERAGE:

Each AccidentEach Accident

GARAGE KEEPERS:LegalDirect ExcessDirect Primary

Comprehensive

Limit of Coverage

Limit Per Location Limit Per Auto

Deductible

Other Than Collision Collision

In-Tow Coverage Limit Per Tow Truck # of Tow Trucks

DEALERS OPEN LOT:Comprehensive

Additional Insured

Waiver of Subrogation

NameAddressInsurable Interest

Broadened Coverage (includes Personal Injury & $50,000 Fire Legal) Hired AutoFire Legal Liability Limit Personal Injury Liability

Limit of Coverage

Limit Per Location Limit Per Auto

Deductible

Other Than Collision Collision

ADDITIONAL COVERAGES:Truth In Lending E&OFederal Odometer Statute E&OTitle E&PInsurance Agents E&OFalse Pretense

PRIOR CARRIER AND LOSS HISTORY

List prior carrier and loss history for the past 3 years. If no losses, please indicate.

Current Carrier Policy Period Policy PremiumPrior Carrier Policy Period Policy PremiumPrior Carrier Policy Period Policy Premium

Date of Loss Amount paid/reserve Description of loss including driver

If there is no prior insurance, check the box.

NOTICE: The policy of insurance applied for does not provide coverage as required by Environmental Protection Agency (EPA) 40 CFR Parts 280 and 281 for underground storage tanks nor coverage under CERLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION.

the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. This application shall not be

be made, and then only as of the commencement date of said policy and in accordance with all term thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the insured.

Witness Date Applicant’s Signature