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*To save this form after the fields are filled in, you will need Adobe Reader 9 or later. If you do not have version 9 or later, please download the free tool at:http://get.adobe.com/reader.National Specialty ProgramsToll-Free: 800-366-5810 Fax: 410-828-8179Contact us: programs@ryansg.comGarage ApplicationPRODUCER INFORMATION:Producer Name: Agency Name:Phone Number: Mailing Address:City: State: Zip:ACCOUNT INFORMATION:Account name:Effective date: Expiration date:Mailing address:City:State: Zip code:County: Normal Business Hours:Fein #:Dealership License Number:Insured Email Address:Website address:Contact name:Contact Phone Number:Years in business:Annual sales: (Required for Service Risks)*If less than 3 years, please provide industry experience:*What positions have been held?LINES OF BUSINESS:Umbrella*PropertyGarage/ Auto*For IM, Crime or Umbrella please include applicable ACORD ApplicationIM*Crime*LEGAL CRIPTION OF OPERATIONS:Non-Franchise DealerNon-Dealer% Retail Sales% Wholesale Sales (Complete Wholesale Questionnaire)Non-Dealer (Please describe operation)Garage Application 031921Page 1 of 8RSGprograms.com
LOCATION #Address:City State ZipLOCATION #Address:City State ZipGARAGE RATING onal InjuryDamage to Rented PremisesIncludeIncludeExcludeExcludeEach Accident Limit: Aggregate Limit: Deductible: Damage to Rented Premises Limit: PIPYesUNINSURED/UNDERINSURED MOTORISTSNoLimit TOTAL # OF PLATESDealerTransporter**NOTE: THIS INFORMATION IS NEEDED TO RATE UNINSURED/UNDERINSURED MOTORISTS COVERAGEMEDICAL PAYMENTSLimit Garage OperationsAutoBothGARAGEKEEPERS:LocationMaximum Valueper AutoAverage Valueper AutoAverage # ofAutos on the LotMaximum # ofAutos on the LotMaximum Value ofAll Autos on the LotPer Vehicle Deductible123Direct PrimaryDirect ExcessStandard Open LotStorage In:Legal LiabilityNon Standard Open LotBuildingAre vehicles stored overnight?YesNoDEALERS OPEN LOT:LocationMaximum Valueper AutoAverage Valueper AutoAverage # ofAutos on the LotMaximum # ofAutos on the LotMaximum Value ofAll Autos on the LotPer Vehicle Deductible123False Pretense Limit: Storage In:Garage Application 031921Standard Open LotLots LitNon Standard Open LotKey StoragePage 2 of 8BuildingAfter HoursRSGprograms.com
Standard Open Lot: Open parking or storage lots enclosed on all sides by a metal cyclone fence not less than six feet in height or bounded on one ormore sides by the wall or walls of a building with no unprotected opening and with exposed sides of the lot enclosed by a metal cyclone or equivalentfence not less than six feet in height, with opening securely locked when unattended.Non-Standard Open Lot: Any other type of protection or fencing or unprotected lot.INTERESTS TO BE COVERED FOR AUTOS HELD FOR SALEOwnedAutosOwner's interestin financed autosOwner &Creditor InterestConsigned Autos**FOR CONSIGNED AUTOS - WE WILL NEED COPYOF CONSIGNMENT AGREEMENTAdditional Garage Coverage:GARAGE/AUTO COVERAGE INFORMATIONDealers Errors & OmissionsOdometerTitle E&OTruth-In-LendingAgent's deExcludeLimitLimitLimitLimit DeductibleDeductibleDeductibleDeductible EMPLOYEE LIST (Please Refer to Employee List Key Below)Last NameFirst NameStateLicense #Violations or AccidentsLast 3 YearsAccidentsMinor ViolationsBirthdateVehicle Use*Position/Status*YesNoHave any drivers been convicted of a major violation in the last 3 years?If yes, list drivers:*EMPLOYEE LIST KEYVehicle Use:A Furnished for Personal UseB Empl not furnished but uses for businessC Non-DrivingD Non-empl w/ occasional access to business vehiclesE Operates customer's vehiclesPosition: 1 Owner , Active Partner2 Inactive Partner3 Manager4 Sales5 Lot Person/Mechanic6 Clerical7 Spouse8 Child9 Occasional Driver10 OtherStatus: F Full Time ( over 20 Hrs. per week)P Part Time (20 Hrs. or less per week)N Non-EmployeeGarage Application 031921Page 3 of 8RSGprograms.com
VEHICLE SCHEDULE IF YOU HAVE SCHEDULED VEHICLESVehicle #Vehicle #YearRadiusMakeUseBody TypeFilings RequiredYes/NoYesNoVINState/FederalACVCoverage Desired? Y/NLiabilityPhysical oYesNoYesNoYesNoYesNoYesNoGVWDeductibleLoss PayeeLoss payee name & addressSURVEY OF HAZARDSGeneral Underwriting .18.19.20.Does applicant have an established store front?YesNoDoes applicant share premises with any other occupants?YesNoIf yes, describe:Any animals on premises?YesNoIf yes, what typeIs applicant a subsidiary of another entity or have any subsidiaries?YesNoIf yes, explain:Does applicant sub contract any work including repair of vehicles held for sale?YesNoIf yes, explain:Has coverage been declined, canceled or non-renewed in last 3 years?YesNoIf yes, explain:Does applicant have any other business ventures not included in this submission?YesNoIf yes, explain:Has applicant had a foreclosure, repossession or bankruptcy in the last 5 years?YesNoIf yes, explain:Has applicant had a judgment in the last 5 years?YesNoIf yes, explain:Are there annually serviced, charged and operable fire extinguishers on premises?YesNoDoes applicant store all flammable liquids in a UL listed fire cabinet?YesNoDoes applicant use UL listed metal containers with self closing lids?YesNoAre no smoking signs posted?YesNoGeneral Housekeeping PracticesModerateFormalInformalEmployee Safety Training PracticesModerateFormalInformalDescribe type of mechanic certification (i.e.: ASE certified)Describe Key Control Procedures:Does applicant have above ground or underground gasoline storage tanks?YesNoIf yes, please describe including age and construction and protection for above ground tanks:Do you export vehicles out of the United States?YesNoIf yes, is the title transferred prior to shipping?YesNoDo you sell autos with salvage titles?YesNoIf yes, please explain:Garage Application 031921Page 4 of 8RSGprograms.com
21. Do you sponsor any racing vehicles or work on racing vehicles?YesNoIf yes, explain:22. Do you do any towing for your business?YesNo23. Do you tow for hire?YesNo24. Do you use an application in your hiring process?YesNo25. Do you check references?YesNo26. Do you run MVR’s prior to hire for drivers or anyone who is furnished a vehicle?YesNo27. Do you repossess autos for yourself or others?YesNo28. Do you use a title verification company?YesNoIf yes, provide name of company:29. If you are a buy here/pay here operation, do you:a. Transfer titles to buyer’s name at time of sale?YesNob. Hold title as lienholder only for final payment?YesNoc.Require a proof of insurance from the buyer?YesNoPRIOR CARRIER/LOSS HISTORY (minimum currently valued expiring plus 3 years)CarrierPolicy TermLoss DateDescription of LossAmount PaidAmountReservedPolicyPremiumTYPES OF VEHICLES SOLD AND/OR REPAIREDSales %%Types of VehiclesPrivate Passenger Autos, Pickups, Vans, SUVs%%RVs Motorhomes, Campers Complete Supplement)%%Heavy Truck/Semi Trailers (Complete Supplement)%%%%Boats (Describe):Power Sports (Jet Skis, ATVs, UTVs)%%Motorcycles (Complete Supplement)%%Golf Carts%%Antique or Classic Cars%%Bucket Trucks, Man Lifts%%%%%%%%%%%%%%%Repair %Garage Application 031921Contractors Equipment (Describe):Agricultural EquipmentEmergency Vehicles (Describe):Buses (list all types):Trailers (other than semi)Other (Describe):Total percentage of operations combined should equal 100%Page 5 of 8RSGprograms.com
DEALERSHIP OPERATIONS1.2.3.4.5.6.7.8.9.10.11.12.13.14.Is applicant part of the National Independent Auto Dealers Association or a Certified Master Dealer?YesNoDoes applicant sell autos on consignment?YesNoIf yes, please provide a copy of the consignment agreementHow many vehicles are sold per year on consignment?Does applicant operate as an Auto Auction?YesNoAre all test drives accompanied by an employee?YesNoAre copies of driver’s licenses & insurance ID cards made prior to any test drive?YesNoIs the test drive route limited to all right-hand turns?YesNoAre overnight test drives allowed?YesNoHow many vehicles are sold per month?Do you require Demo Agreements for anyone furnished a Demo?YesNoIf yes, does the agreement include a deductible provision?YesNoWho transports vehicles to your location for sale after acquisition?Maximum Radius of Pick Up & Delivery # of Trips # of EmployeesWhat type of repair work is commonly completed on vehicles held for sale?Does applicant rent, lease or loan vehicles?YesNoNON-DEALER OPERATIONS - Provide approximate percentage for all operations - Total must equal 100%Airbag install, service or repair%Mobile Auto Repair%Alarm, Stereo or Navigation Systems%Oil/Lube Services%Auto Dismantling/Salvage Yard%Parking Lots & Garages (Self Park)%Body Shop: (see questions below)Brake Repair%Parts Sales (Uninstalled)Gross Receipts% Car Wash - Full Service%Parts Manufacturing/Rebuilding%Convenience Store%Gross Receipts Gross Receipts:Detailing: %Describe Parts:Performance Enhancements%Maximum pick up delivery distance:Any turbo or nitrous installation?Driveaway Contractor Services:%Tire Sales/Service (Complete Supplement)%Frame Straightening, Cutting%Trailer Hitch Installation%Welding (See Questions below)Fuel Tank Repair%Bolt On %TransmissionGasoline Station - Full Service%Upholstery%Gallons of Gas sold annuallyIgnition Interlock Systems %Valet Parking (complete supplement)Vehicle Conversions - Structural:%%Impound Yards%Welding%Lift/Lowering Kits%Window Tinting%Machine Shop Rebuilding%Windshield Installation/Repair%WeldedYesNo%%Other (Describe):PAINT AND BODY SHOP OPERATIONS1.2.3.4.5.6.Is spray booth NFPA compliant?YesNoAre booth and paint mixing area protected by an automatic sprinkler or dry suppression system?YesNoIs paint mixing area enclosed in a non-combustible enclosure with a self-closing door?YesNoDo both and paint mixing area have explosion proof electrical systems?YesNoAre all filters regularly cleaned and changed?YesNoMaximum gallons of flammable solvent based liquid maintained at any one time?FRAME STRAIGHTENING OPERATIONSProvide year, make and model of frame machineGarage Application 031921Page 6 of 8RSGprograms.com
PROPERTY- For additional locations copy this pageSubject of InsuranceBldg. CoverageBldg. 1Bldg. 2Bldg. 3Business Personal PropertyBldg. 1Bldg. 2Bldg. 3Business IncomeBldg. 1W/ Extra ExpenseW/O Extra ExpenseBldg. 2W/ Extra ExpenseW/O Extra uation:ACV or RCCoverage Form:Basic, Broad orSpecial Monthly Limit of Indemnity1/3rd1/4th1/6th Maximum Period ofIndemnityBldg. 3W/ Extra ExpenseW/O Extra ExpenseDeductible BUILDING INFORMATION:BuildingNo.Year BuiltBuildingConstructionTotal Sq. Ft.OccupiedBUILDING IMPROVEMENTS: Provide year updatedBldg. 1WiringRoofNo. ofStoriesPlumbingSprinklerSystem Yes/NoFire ProtectionSystem Yes/NoCentral StationMonitoredAlarm CLocal AlarmYes/NoYesNoNoYesNoNoYesNoOtherBldg. 2Bldg. 3INLAND MARINE & CRIME (Please include applicable ACORD Form)Employee Tools Deductible Employee Dishonesty Deductible Forgery Deductible Money Securities (Inside & Outside) Deductible Other: Deductible Garage Application 031921Page 7 of 8RSGprograms.com
FRAUD WARNINGS AND ATTESTATIONThis application does not bind You or Us to complete the insurance, but it is agreed that the information contained herein shall be thebasis of the contract should a policy be issued.FRAUD WARNING APPICABLE IN THE STATE OF NEW YORKAny person who knowingly and with intent to defraud any insurance company or other person files an application for commercialinsurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, orconceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with suchapplication or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft,destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or aninsurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed fivethousand dollars and the value of the subject motor vehicle or stated claim for each violation.FRAUD WARNINGAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claimcontaining any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits afraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.APPLICANT'S SIGNATURE: DATE:PRODUCER'S SIGNATURE: DATE:LICENSED AGENT: DATE:(Applicable in Iowa only)AGENT NAME: AGENT LICENSE NUMBER:(Applicable to Florida Agents Only)IMPORTANT NOTICEAs part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, generalreputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of thereport, if one is made, will be provided.FULLY COMPLETED AND SIGNED APPLICATION IS REQUIRED TO BIND COVERAGE. NO EXCEPTIONS!RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is asubsidiary of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from thepublic. Some products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License# 0G97516). 2021 Ryan Specialty Group, LLCGarage Application 031921Page 8 of 8RSGprograms.com
Standard Open Lot: Open parking or storage lots enclosed on all sides by a metal cyclone 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 exposed sides of the lot enclosed by a metal cyclone or equivalent
