GARAGE & AUTO DEALER Application ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT.

Broker Name: Broker Location: Broker Contact:

Retail Agent Name: Retail Agent Address: Retail Agent Phone Number:

APPLICANT INFORMATION Proposed effective date:

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to

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Name of Applicant (include DBA) ___ Individual

Applicant is:

___ Joint Venture

___ Partnership

___ LLC

___ Other Organizational Structure:

Mailing Address: Contact:

Phone Number:

Website: Number of years in business:

Number of years experience in this field:

Description of Operations: Location #1 Location #2 Location #3

EMPLOYEE AND NON-EMPLOYEE INFORMATION Loc. #

Name

Drivers License Number & State

Date of Birth

Violations or Accidents within the Past 3 years

Job Description or Relationship to Insured

Full Time or Part Time

(see below)

(see below)

Have all owners, employees, non-employees, household members, independent contractors who work for the business and drivers who may operate your vehicles or vehicles in your care, on a regular or infrequent basis been disclosed above? JOB DESCRIPTION OR RELATIONSHIP TO INSURED: Owners, Partners, Officers, Salespersons, Managers. Clerical staff, Lot personnel, Mechanics. Independent Contractors. Contract Driver - provide name(s), or Blanket Contract Drivers.

Furnished an Auto for Personal Use? Yes/ No

___ Yes ___ No

Inactive Owners, Inactive Partners, Inactive Officers. Non-Employee - Spouse, Domestic Partner, Children.

PART TIME: Employees working less than 20 hours per week shall be considered Part Time.

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CAG 7000 11/16

INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS SOLD / REPAIRED Boats - Other Than Jet Skis*

Sales ____ %

Repair ____ %

Busses*

____ %

____%

Motorcycles*

____ %

____ %

Bucket Trucks / Cranes / Scissor Lift* Contractors Equipment*

____ % ____ %

____% ____ %

ATVs, UTVs, Scooters, Snowmobiles* Private Passenger, Light & Medium Truck

____ % ____ %

____ % ____ %

Emergency Vehicles*

____ %

____ %

Race Cars / Street Rods

____%

____ %

Farm Equipment* Public Livery / Transportation

____ % ____ %

____% ____ %

Recreational Vehicles, Motor Coaches

____% ____ %

____ % ____ %

Golf Carts

____ %

____ %

____ %

____ %

Heavy Truck (over 26,000 GVW)*

____ % ____ %

____ % ____ %

____ %

____ %

Jet Skis* Kit Cars or Other Auto Manufacturing

____ %

Sales ____ %

Mobile Homes (non-motorized)

Semi Trailers* Trailers - Other than Semi Trailers OTHER (Provide complete description) :

Repair ____%

____ % *Supplemental application required

UNDERWRITING INFORMATION Do you: ___ Yes ___ No Engage in any other operations? ___ Yes ___ No Engage in fuel conversion? Engage in performance enhancements? ___ Yes ___ No Loan, Lease or Rent autos to others? ___ Yes ___ No Engage in auto pawning or auto title loans? ___ Yes ___ No Dismantle autos or have salvage operations? ___ Yes ___ No ___ Yes ___ No Own or operate a car crusher?

Stack salvaged autos more than 2 high? Work at airport, seaport or railroad premises? Engage in Breathalyzer / ignition interlock? Manufacture / Fabricate any auto parts? Structurally alter or convert vehicles from their original factory design?

___ Yes ___ Yes ___ Yes ___ Yes ___ Yes

___ No ___ No ___ No ___ No ___ No

EXPLAIN ALL YES REPONSES:

Do you: Secure all keys in a lock box or a secure cabinet away from vehicle? Obtain certificates of insurance from all sub-contractors? Accompany customers in the service/repair area? Store all paints and solvents in a fire resistive cabinet outside the paint booth? Confine all spray painting operations to an UL approved booth? If No, is there explosion proof lighting and adequate ventilation?

___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes

___ No ___ No ___ No ___ No ___ No ___ No

___ N/A ___ N/A ___ N/A ___ N/A

PRIOR INSURANCE COMPANY AND LOSS HISTORY Current Carrier Prior Carrier Prior Carrier Prior Carrier Prior Carrier Date of loss

Policy Period Policy Period Policy Period Policy Period Policy Period Amount paid / reserve

Policy Premium Policy Premium Policy Premium Policy Premium Policy Premium

Description of loss

Driver involved

___ If there is No Prior Insurance, check the box. ___ If there are No Prior Losses, check the box. Any policy or coverage Declined, Cancelled or Non-Renewed during the prior Three (3) years? (Missouri Applicants - Do not answer this question).

___ Yes

___ No

If yes, explain:

Dealers proceed to page 3, Non-Dealers proceed to page 4. 2 of 5

CAG 7000 11/16

DEALER OPERATIONS ___ Non-Franchised Dealership ___ New Auto/ Franchised Dealership

Retail: Internet: Wholesale:

Number of Dealer Plates Plate numbers: Do you Lease, Rent, Loan or Sell plates to others? If yes, explain: How are plates are being used? Where do you store plates when not in use?

% % % ___ Yes

Auction: Consigned:

% %

___ No

Do you: Obtain Drivers License and Proof of Insurance before all test drives? Accompany all test drives? Allow extended or overnight test drives? Offer In-house financing or Buy Here / Pay Here? If yes, are titles transferred to customer at the beginning of the finance period and your business named as a lienholder? Buy or sell autos in the following states? Check all that apply. State Kansas Kentucky Maryland Michigan Minnesota

Buy

Sell

Number of times per year

(Provide copy of consignment agreement.)

State New Jersey New York North Dakota South Carolina

Buy

___ Yes ___ Yes ___ Yes ___ Yes

___ No ___ No ___ No ___ No

___ Yes

___No

Sell

Number of times per year

DEALERS COVERAGES & LIMITS Radius of pickup & delivery Auto Dealers Liability

___ Symbol 22 & 29 or ___ Symbol 21

Deductible

___ 0 - 300 Miles

Covered Autos Liability General Liability BI & PD Damage to Premises Rented Personal & Advertising Injury General Liability Products & Work Performed Loc & Operations Medical Payments ___ Auto Medical Payments ___ Hired Auto

___ 501 - 1,000 Miles

___ 301 - 500 Miles

same as above

___ Broad Form Products

Each Accident Each Accident Any One Premises Any One Person or Organization Aggregate Limit Aggregate Limit Any One person Any One person ___ Assault & Battery Buyback Limit per Statute Each Acc. Each Acc. Each Acc.

___ Personal Injury Protection: ___ Uninsured Motorists Coverage ___ Underinsured Motorists Coverage ___ Uninsured Motorists Property Damage Dealers Physical Damage Symbol 31

___ Comprehensive

___ Unlimited

Owned Auto Coverage: Limit Location 1 Limit Location 2 Limit Location 3

Maximum Limit Per Auto Deductible Per Auto

___ Specified Causes

___Vehicle storage: ___ Building ___ Standard Lot* ___ Non-Standard Lot*

___ Collision

___Theft Buyback, for Unprotected Lot. (subject to guidelines) Types of Autos:

___ New Autos

___ Unprotected Lot*

___ False Pretense

___ Used Autos, Demonstrators, Service Vehicles

Interest(s) Covered (Check all that apply): Your interest in covered autos you own ___ Your interest & interest of any creditor/ loss payee ___ Creditor/Loss Payee: Name: Address:

___ Your interest only in financed autos ___ Consigned Auto

*Standard Lot: During non-operating business hours all entrances, exits, or openings and the entire perimeter is surrounded by fences with gates or heavy chains and locks. *Non-Standard Lot: Any other type of protection. *Unprotected Lot: No theft barrier.

Dealer's Acts, Errors & Omissions:

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___ Title E&O

___ Federal Odometer E&O

___ Truth In Lending E&O

___ Insurance Agents E&O

CAG 7000 11/16

NON-DEALERS / SERVICE OPERATIONS Alarm, Stereo or Navigational System Auto Detailing (other-than car wash - full service) Auto Dismantling / Salvage Yard Payroll: Auto Maintenance or Repair Incl Bed liner Auto Part Sales - New Parts Only (Uninstalled) Receipts: Auto Part Sales- Used Parts Only (Uninstalled) Receipts: Body & Paint Shop Butane, Propane or other Liquefied Gas Sales Car Wash - Full Service Convenience Store Receipts: Driveaway Contractor Frame or Unibody Straightening ___ Repair ___ Modification Gasoline Station: Full Service Gasoline Station: Self Service only Convenience Store Receipts:

% % % % % % % % % % % % % %

Handicap Vehicle Modification Impound Yards Lift Kit/ Lower Kit Installation, Service or Repair Mobile Auto Repair / Roadside Assistance Mobile Tire Sales, Installation, Service or Repair Oil/Lube Service Parking Lots & Garages - self park only* Rim Repair Storage Lots Tire Sales, Installation, Service or Repair Trailer Hitch Installation or Repair Upholstery Valet Parking* Van Conversion ___ Structural ___ Non-Structural Welding: Window Tinting Windshield Installation/Repair Wrecker Service: For-Hire Wrecker Service: Not-For-Hire Other:

% % % % % % % % % % % % % % % % % % % %

*Supplemental application required

NON-DEALER COVERAGES & LIMITS Radius of pickup & delivery

___ 26 - 100 Miles

___ 0 - 25 Miles

Auto Only Other Than Auto Other Than Auto

Non-Dealer Liability Symbol 29 Deductible

___ 101 - 200 Miles

same as above

___ Registration / Repairer / Transporter Plates Plate Numbers: ___ Personal Injury Protection ___ Uninsured Motorists Coverage ___ Underinsured Motorists Coverage ___ Uninsured Motorists Property Damage

Specified Causes ___ Comprehensive ___ Collision

Each Accident Each Accident Aggregate Limit

___ Personal Injury Liability ___ Broadened Coverage ( includes Personal Injury & $100,000 Damage to Rented Premises) ___ Damage to Rented Premises Any One Premises ___ Loc & Operations Medical Payments Any One person ___ Auto Medical Payments Any One person ___ Hired Auto ___ Assault & Battery Buyback

Garagekeepers Symbol 30

___ Over 200 Miles

___ Broad Form Products ___ Liquor Liability Buyback # of Plates: Limit Per Statute Each Acc. Each Acc. Each Acc.

Limit Location 1 Limit Location 2 Limit Location 3 ___Vehicle storage:

___ Building ___ Standard Lot*

Maximum Limit Per Auto Deductible Per Auto ___ Non-Standard Lot*

___Unprotected Lot*

___ Theft Buyback, for Unprotected Lot (subject to guidelines) ___ Legal Liability ___ Direct Excess ___ Direct Primary

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*Standard Lot: During non-operating business hours all entrances, exits, or openings and the entire perimeter is surrounded by fences with gates or heavy chains and locks. *Non-Standard Lot: Any other type of protection. *Unprotected Lot: No theft barrier.

CAG 7000 11/16

ADDITIONAL INSUREDS Lessor of Leased Equipment (CA 2047) Grantor of Franchise (CA 2049) Owner of Garage Premises (CA 2509) Designated Person or Organization (CAG 1712 / CAG 1912) Scheduled Person or Organization Primary and Non-Contributory (CAG 1752 / CAG 1952) Waiver of Subrogation (CA 0444) ADDITIONAL INSURED / WAIVER OF SUBROGATION INFORMATION

Name: Address: Relationship to Insured: Applies to location:

___ # 1

___ # 2

___ # 3

AUTO TRANSPORT / TOWING How do you transport autos? Driven by: ___ Employee Towed by: ___ Employee

___ Temporary / Contract Driver ___ Temporary / Contract Driver

Third party Tow Truck or Car Hauler Certificate of Insurance on file?

___ Yes

___ No

Do you: Repossess vehicles for others? ___ Yes ___ No Require a Federal Filing? ___ Yes ___ No Tow, Haul or Carry more than 2 autos at once? ___ Yes ___ No Tow For-Hire? ___ Yes ___ No If yes, is In-Tow Coverage required? Number of Tow Trucks:

SCHEDULED AUTO LIABILITY OR PHYSICAL DAMAGE COVERAGE (Symbol 27) Available in AL, CA, MS, MO, NM, OH, SD, TN, TX, VA, WA, WY. Towing exposure: The vehicle, trailer, tow bar, or tow dolly must be specifically scheduled on the policy.

Coverage: (check all that apply) ___ Liability ___ Uninsured/Underinsured ___ Personal Injury Protection

___ Specified Causes ___ Comprehensive ___ Collision

Yes Yes

No No

Year: Make & Model: VIN: GVW: Radius of Operation: Miles Stated Value: $ ___ Yes ___ No Is vehicle titled to the Named Insured? Lessor - Additional Insured & Loss Payee Name: Address:

Year: Make & Model: VIN: GVW: Radius of Operation: Miles Stated Value: $ Is vehicle titled to the Named Insured? ___ Yes ___ No Lessor - Additional Insured & Loss Payee Name: Address:

Check all that apply: ___ Service Use ___ Personal Use ___ Rental / Loaner

Check all that apply: ___ Service Use ___ Personal Use ___ Rental / Loaner

___ Towing Not For-Hire ___ Towing For-Hire ___ Trailer, Tow Dolly or Car Hauler

___ Towing Not For-Hire ___ Towing For-H ire ___ Trailer, Tow Dolly or Car Hauler

ADDITIONAL INFORMATION

NOTICE: The policy of insurance applied for does not provide coverage as required by Environmental Protection Agency (EPA) 40 CFR Parts 280 and 281 for underground storage tanks nor coverage under CERLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION. Any person who knowingly and with intent to defraud the Company filing an application for insurance 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. This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the insured. Applicable in NY: Any person who knowingly and with the 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 throusand dollars and the stated value of the claim for each such violation.

Applicant's Signature 5 of 5

Date

Witness CAG 7000 11/16