Applicant’s Name:

First Last

Mailing Address:

Location Address:

PROPOSED EFFECTIVE DATE:

From_____To_____

GENERAL INFORMATION:

Indicate operations applicable to applicant:

Number of years in business:

Number of years at this location:

Does applicant have any vehicle dealer operations?

Yes

No

If yes, does applicant have an auto dealers license?

Yes

No

Does applicant pick up or deliver automobiles, or drive customers’ automobiles beyond brief test drives?

Yes

No

Where are keys to customers’ autos kept:

At night?

Where are keys to customers’ autos kept:

During business hours?

Where are customers’ autos kept at night?

Inside

Outside

If autos are kept outside, is lot protected on all sides by fence, chain, cable or pipe welded to or connected through steel, concrete or heavy timber post and secured with a heavy gauge steel padlock?

Yes

No

If no, explain:

Is the parking area lighted at night?

Yes

No

Any other insurance with this company or being submitted?

Yes

No

If yes, list name(s) and/or policy number(s):

Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?

Yes

No

If yes, explain:

OPTIONAL MARKET SEGMENTS ENDORSEMENTS

Is MS AS 01 (or state equivalent)—Auto Service Risks (Property Coverage extensions) coverage selected?

Yes

No

Increased Limits for Optional Auto Services Endorsement MS AS 01 (or state equivalent):

Fire Department Service Charge $

Money and Securities $

Outdoor Signs $

Employee Tools $

Accounts Receivable $

FRAUD WARNING

NOTICE TO ALABAMA APPLICANTS:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination there of.

NOTICE TO CALIFORNIA APPLICANTS:

For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS:

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

WARNING TO DISTRICT OF COLUMBIA APPLICANTS:

It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant

NOTICE TO FLORIDA APPLICANTS:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO MARYLAND APPLICANTS:

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEW JERSEY APPLICANTS:

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO OHIO APPLICANTS:

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS:

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NEW YORK FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.