Dealer and Service Insurance Questionnaire

Owner's Name: *

Business Name (Including DBA): *

Phone Number: *

Email: *

Mailing Address *

City, State Zip *

Garaging Address: *

City, State Zip: *

Business Status: *

Do You Have Insurance? *

Name of Current or Prior Insurance *

If you do not have current or prior insurance please enter N/A

Kind of Service

Checkboxes *

What Limits of Liability Would You Like?

How Much Inventory Do You Have (Dollar Amount)?

Repair Shop: *

If Yes, What is Your Specialty? *

If no please enter N/A

Do you have a Tow Truck or Car Hauler? *

Are You Involved In Car Racing? *

How Many Dealer Plates Do You Have? *

Maximum Number of Vehicles On The Lot? *

Average Value of Vehicle: *

Maximum Value of Vehicle: *

How Many Years in Business? *

How Many Years at Current Location? *

Driver 1 - Drivers Name: *

Driver 1 - Date of Birth: *

Driver 1 - DL Number: *

Driver 1 - Tickets or Accidents in the Past 3 Years? *

Drivers 2 - Name: *

Driver 2 - Date of Birth: *

Driver 2 - DL Number: *

Driver 2 - Tickets or Accidents in the Past 3 Years? *

Are Any Vehicles Driven Home or For Personal Use? *