Step 1 of 4 25% Garage QuestionnaireContact Name* Company Name/DBA* Phone* Fax E-mail* Company Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Garage Questionnaire (continued)Year Business Started # of locations Annual Sales Employee Count FEIN # Current Insurance Company Policy Expiration Date Any Losses Yes No Please explain any losses - include estimated date, claim cost, etcAverage # of Cars in Care Garagekeepers Limit Building Value Year Built Square Feet Contents Value Alarm Systems Yes No Central/Local Alarm Driver ListFirst and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # First and Last Name First Last DOB Driver License # Worker's CompensationTotal Mechanic Payroll (8380) Employee Count Total Clerical Payroll (8810) Employee Count Total Body Technician Payroll (8393) Employee Count Additional Comments or Coverages Needed Δ
