Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
Auto Body
First Name:
Last Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Refereed You To Our Site?

Property Information
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Property County:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
How Many Stories:
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Is The Business In A Brush Area? yes no  
Is There Storage More Than 1500 Sq Ft? yes no  
Are There Smoke Detectors At This Location? yes no
Smoke Alarm: yes no
Theft Alarm:
Fire Alarm:
Fire Extinguisher: yes no
Deadbolts On All Doors? yes no
Circuit Breakers: yes no
Electrical Updated:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Heating - Air Conditioning, Central? yes no
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers: 
Is The Parking Lot Under Your Protection?

yes no

Underwriting Information
Please Describe the Nature of Your Business  

Number of Owners:
Number of Employees:
Number of Employees that work on vehicle:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Annual Sub Costs:
Business License Number:
Bureau Auto Repair Number (if different):
License Type:
Years of Experience:
How many years have you operated under your current business name:
Have you used any other business names during the past 5 years: No Yes  
Any work done on Commercial, Antique, Classic Cars: No Yes  
Number of Vehicles kept Overnight:
Where are the Vehicles stored Overnight:
How are the keys secured:
Do you loan your cars out during repairs: No Yes  
Number of pickup or vehicle deliveries per day:
Average distance one way to pickup or delivery:
Selling or consignment of vehicles: No Yes  
Average number of vehicles stored overnight:
Any LPG sales: No Yes  
Do you have a safety program in place: No Yes  
Do you test drive the repaired vehicles: No Yes  
If yes, do you check the driving records of those driving: No Yes  
Do any spray painting: No Yes  
If yes, is it in a UL approved booth: No Yes  
How many cars do you paint a week:
Average vehicle value stored overnight:
Average TOTAL value of all vehicles stored overnight:

Misc Information
 

Current Insurance Company:

 

Current Premium:
Prior coverage ever been declined: No Yes  
Ever file bankruptcy: No Yes  
Losses-Claims in the last 5 years:   
If yes, date, amount paid and description of each loss-claim

Coverage Information
 

Building Limit Requested:

 

Office Contents Limit Requested:
Shop Contents Limit Requested:
Loss of Rents Limit Requested:
Auto Liability Limit Requested While Test Driving:
Maximum Per Vehicle Damage (Collision) Loss Limit While Test Driving:
Maximum Per Vehicle Damage (Comp) Loss Limit While The Customers Vehicle Is Parked At Your Location:
Liability Limits Requested:
Questions or Comments
to help the Agent: