| APPLICANT: |
| Name: | |
| Address: | |
| City/State/ZIP | |
| Phone: | |
| Email: | |
| STORAGE: |
| 1. Vehicle kept in locked storage? | |
| 2. Loaned or rented to others? | |
| If yes, explain: | |
| 3. Sactioning body: | |
| Class: | |
| 4. Are you required to add others for coverage under this policy? | |
| 5. Are trailers enclosed? | |
| If no, explain: | |
| 6. Deductibles: Trailer: | |
| Scheduled property, Misc. equipment, Tools and Spare parts: | |
| 7. Aggregate limit: Maximum amount of payment any one occurrence: | |
| 8. Lay Up Period (from/to): | |
| Is all equipment laid up and in storage for more than 4 months a year? | |
| If yes, how long? | |
| Is storage facility different from your mailing address? | |
| 9. Structure: Garage: | |
| Roof: | |
| How many garage doors? | |
| Are these doors locked? | |
| If no, explain: | |
| How many windows? | |
| Are these windows barred? | |
| Does the garage have an operating sprinkler system? | |
| Are flammables or chemicals stored in this garage? | |
| Is there a fire extinguisher in the garage? | |
| Has an alarm system been installed? | |
| If Yes, Details: | |
| Is the alarm in working condition? | |
| Do you store any covered items outside while at your shop? | |
| If Yes, Details: | |
| Is the outside yard adjacent to the shop secured? | |
| If Yes, Details: | |
| Please list any other precautions taken in order to reduce loss: | |
| 10. Remarks: ( Use for general information )
Certificates of insurance, peculiarities of coverage, special coverages, conditions or operations that might affect the exposure. | |
| 11. If no auto coverage has been submitted in conjunction with this account please provide a complete drivers list including name, date of birth, driver's license number and license state. |
| Drivers List #1 |
| Name: | |
| DOB: | |
| DL#: | |
| State: | |
| Drivers List #2 |
| Name: | |
| DOB: | |
| DL#: | |
| State: | |
| Drivers List #3 |
| Name: | |
| DOB: | |
| DL#: | |
| State: | |
| 12. Schedule of Equipment: Include Competition Vehicles, Parts, Tools , Equipment, Etc. to be insured under this policy. |
| Chassis #1: |
| Competition Vehicle/Race Car Chassis: | |
| Price Includes Engine? | |
| Insured Value (stated amt): | |
| Chassis #2: |
| Competition Vehicle/Race Car Chassis: | |
| Price Includes Engine? | |
| Insured Value (stated amt): | |
| Equipment #1: |
| Equipment ( tools, spare parts, etc. )
List all items over $1,000: | |
| Serial #: | |
| Insured Value (stated amt): | |
| Equipment #2: |
| Equipment ( tools, spare parts, etc. )
List all items over $1,000: | |
| Serial #: | |
| Insured Value (stated amt): | |