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Home > Business > Property/Liability Full Service Car Wash Insurance Application
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Property/Liability Full Service Car Wash Insurance Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

General Information
First Name *
Last Name *
Date
First Named Insured
Effective Date
Mailing Address
Street *
City *
State / Province *
ZIP / Postal Code *
Location Address
Street Address
City *
State / Province *
ZIP / Postal Code *
Location County
Additional Information
Primary Phone Number *
Fax Number
E-Mail Address *
Application Type




Interest

What percentage of building is owner occupied?


Number of years in car wash business
If Less than 3 years provide prior business experience
Carrier & Premium Information
Enter Up to 3 Carriers
From Date
To Date
Company Name
Premium
From Date
To Date
Company Name
Premium
From Date
To Date
Company Name
Premium
Enter All Claims and Occurrence For the Prior 3 years
Enter Up to 4 Claims
Occurence Date
Describe Claim
Claim Date
Amount Paid
Occurence Date
Describe Claim
Claim Date
Amount Paid
Occurence Date
Describe Claim
Claim Date
Amount Paid
Occurence Date
Describe Claim
Claim Date
Amount Paid
Underwriting and Coverage Information
Number of Full Service Conveyors
Type



Hours of Operations
Number of Employees
Do you have Workers Compensation Insurance?

Underwriting and Coverage Information
Detailing

Vehicle Repair

Windshield

Auto Sales

Towing

Convenience Store

Food Service

Describe
Dog Wash

Other

Describe
Lube

Emissions

Lease/Rental

Mini Storage

Gas Sales

Annual Revenue
Other Profit Centers Annual Revenue
Maximum number of customer vehicles in your control at one time
Average value customer vehicle
Who is allowed to move/drive customer's vehicles?
Do designated drivers wear special clothing to clearly distinguish them from non-drivers?
Are handicapped-equipped vehicles operated by managers only?

Are customers allowed in wash area?

Explain procedure for releasing vehicle back to customer
Year Building Constructed
Number of vehicles washed per month
Are vehicles kept overnight?
If building over 25 years indicate year updated
Wiring
Heating
Plumbing
Roof
Building Construction



Property Limit Replacement Cost
Building #1 Square Footage
Building Value
Equipment Value
Contents (other than equipment)
Building #2 Square Footage
Building Value
Equipment Value
Contents (other than equipment)
Vacuum/Canopy Isle Square Footage
Building Value
Equipment Value
Contents (other than equipment)
Free Standing Signs
Other Structures (Describe)
Mobile Equipment (pit cleaner, backhoe) describe
Additional Interests
Mortgage
Name
Address
City
State
Zip Code
Loss Payee
Name
Address
City
State
Zip Code
Additional Insured
Name
Address
City
State
Zip Code
Are premises protected by alarm system?

If Yes,

Surveillance cameras?

Do exterior doors have double cylinder dead bolt locks?

Average cash kept overnight?
Do you accept credit/debit cards?

Premises well lighted?

Is there a safe on premises?

Frequency of deposits?
If so, do you verify auto insurance and limits?

Pick Up and Delivery (Complete this section if the operation will provide this service)
Does this service include

Radius of pick-up and delivery
Driver Information
Driver 1
Employee Name
Date of Birth
Title
Driver's License Number
Driver 2
Employee Name
Date of Birth
Title
Driver's License Number
Driver 3
Employee Name
Date of Birth
Title
Driver's License Number
Driver 4
Employee Name
Title
Date of Birth
Driver's License Number
Lube & Oil Facility (Complete this section is the operation will provide this service)
Have all employees attended a training program?

Is all work double checked by a manager or another employee before vehicle is released to the customer?

Are customers allowed in the garage area?

Other comments which may indicate this risk is above average and/or demonstrate above average security measures
Other
Additional information or remarks
Application completed by
If Agent/Broker, Name of Agency
Agent Mailing Address Copy
Address
City
State
Zip Code
Phone Number
Fax Number
Email
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Joplin, MO 64804
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