REPAIR SHOP / GARAGE QUOTE FORM (Acord 125)

First Name * Last Name *
Mailing Address *
Email Address * Phone *
Date of birth * Social Security No.
State: * City: *
Zip Code: * Corporation's Name: *
What type of Business:
What are your hours of operation: * Do you have your federal ID Number available: *
What is your current insurance company: Expiration Date:
Current Premium:   DO YOU HAVE ANY CLAIMS OR LOSSES:
(Only if this business HAS OR HAS HAD insurance, REQUEST 3-YEAR LOSS RUNS)
Say: "PLEASE FAX US YOUR 3-YEAR LOSS HISTORY"

PROPERTY SECTION (Acord 140)

How many buildings are on the premises: * How many coverage do you need for building #1: *
How many coverage do you need for building #2: * What is the square footage of building #1:
What is the square footage of building #2: How much contents coverage do you need:
Car wash EQUIP. Coverage: How many pumps do you have:
How much pumps coverage do you need: How much canopy coverage do you need:
Is your canopy attached to the building: How much you need Business income Coverage:
Crime Coverage: What is your building construction type:
What year was it build:
Central Station Alarm :
Sprinkler System:

LIABILITY SECTION (Acord 126)

How much liability coverage do you need:
In order to provide you with the best possible quote, please provide the following figures:
Gross annual C-Store Sales: $ Gasoline Gallons per year:
Beer & Wine Sales: $ Cooking/Deli Sales: $
Annual Car wash Sales: $ Check Cashing Sales: $
If Repair shop, # of Mechanic(s): Repair shop Sales: $
NOTES: *