Genesee General of Colorado On Line Quote Request-Garage

Producer

AGENCY NAME*

Phone*

FAX

Email*

CONTACT NAME

Route To

UNDERWRITER

Insured

NAME*

LOCATION ADDRESS

STREET

City

State

Zip

Untitled

INSURED'S WEBSITE

YEARS IN BUS*

YEARS OF EXPERIENCE

DESCRIPTION OF OPERATIONS

DOES INSURED SELL NEW OR USED AUTO PARTS?

Yes
No

DOES APPLICANT HAVE A UL APPROVED SPRAY BOOTH?

Yes
No

If yes, is it approved?

Employee and Non-Employee Information

You must complete the following information for all employees, drivers, and household members.

Employee Info

Name

Age

Violations

Violations/accidents for last 3 yrs

Job Duties

Hours Worked

Auto Use

Prior Carrier & Loss History

CARRIER*

Policy Premium*

If there is no prior insurance, check the box.

Policy Period

Total Paid

Number of Claims

If there are no prior losses, check the box.

Coverages and Limits

GARAGE LIABILITY

Auto

Limit of Liability - Each Accident

Other Than Auto

Limit of Liability - Each Accident

Deductible

Auto

Limit of Liability - Aggregate Limit

DEALERS OPEN LOT

Coverages

Comprehensive
Specified Perils
Collision
False Pretense

Limit Coverage Per Location

Deductible

Other Than Collision

Limit Coverage Per Auto

Deductible

Collision

GARAGEKEEPERS

Coverages

Comprehensive
Specified Perils
Collision

Limit Coverage Per Location

Deductible

Other Than Collision

Limit Coverage Per Auto

Deductible

Collision

Select one of the following

Legal Liability
Direct Excess
Direct Primary

LOT PROTECTION

Select one of the following that best describes how the applicant's premises is protected:

Standard Open Lot - Open Parking storage Lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet in height; or a combination gates, posts, or heavy chains, locks or bounded on one or more sides by the wall or wall of building with no unprotected openings.
Non-Standard Open Lot - Lots that are all other open lot locations; or unroofed space and buildings not securely enclosed and locked when unattended.
Unprotected - Open storage with no theft barriers.
Building - Storage of autos in secured, locked building.

MISC COVERAGES

In-Tow Coverage

For-Hire
Not-For-Hire

Limit Per Tow Truck

# of Tow Trucks

Medical Payments - Auto

Medical Payments - Garage Operations

Broadened Coverage (includes Personal Injury & $50,000 Fire Legal)
Fire Legal Liability
Damage to Rented Premises
Personal Injury Liability
Broad Form Products

Fire Legal Liability Limit

Damage to Rented Premises Limit

Additional Insured

Yes
No

Name

Address

Insurable Interest

Waiver of Subrogation

Yes
No

Uninsured Motorists Coverage

Each Accident

# of Dealer Tags

Underinsured Motorists Coverage

Each Accident

Personal Injury Protection

Per Statute

Radius of Pickup & Delivery

Dealer's Errors & Omissions

Title E&O
Truth In Lending E&O
Federal Odometer E&O
Insurance Agents E&O

Service Vehicles

Include Tow Trucks, Car Haulers & Wreckers or Specifically Described Autos:

Filings Required?

No
Yes

If yes, list MC# or Certificate #

Vehicle Info

Year

Make

Body Type

Serial #

GVW

Phy Damage Limit

Loss Payee

ADDITIONAL INSURED

Name

Address

Insurable Interest

Optional Coverage Not Listed

Comments

File

Max. file size: 50 MB.

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Jencap Insurance Services – Colorado Office: Online Quote Request-Garage

Producer

Route To

Insured

LOCATION ADDRESS

Employee and Non-Employee Information

Employee Info

Prior Carrier & Loss History

Coverages and Limits

GARAGE LIABILITY

DEALERS OPEN LOT

GARAGEKEEPERS

LOT PROTECTION

MISC COVERAGES

Service Vehicles

Vehicle Info

ADDITIONAL INSURED

Comments