Auto Service Application Applicant’s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone: Web site Address: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE" Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company Other (Specify): A. GENERAL INFORMATION: 1. Number of years in business: Number of years at this location: 2. Indicate operations applicable to applicant: Automobile Parts & Supplies Store Gasoline Station—full service—with service/repair shop Automobile Quick Lubrication Services Gasoline Station—self and full service combined—with service/repair shop Automobile Repair or Service Shop Gasoline Station—self-service—without convenience Automobile Storage and no service/repair shop Car than self-service Mobile Repair/Detailing Car Wash—self-service Parking—public—not open air Convenience Store/Gasoline Station—full Parking—public—open air service—with service/repair shop Roadside Assistance Convenience Store/Gasoline Station—self and full service combined—with service/repair shop Tire Dealer Convenience Store/Gasoline Other (describe): service/repair shop (refer to Grocery/Convenience Store Program) 3. Inspection Contact Person: Telephone: 4. Does applicant have any vehicle dealer operations? Yes No 5. Does applicant have other business ventures for which coverage is not requested? Yes No
Auto Service Application Applicant’s Name: Mailing Address: Location Address: Web site Address: Agency Name: Agent: Address: E-mail: Phone: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE" Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company Other (Specify): A. GENERAL INFORMATION: 1. Number of years in business: Number of years at this location: 2. Indicate operations applicable to applicant: Automobile Parts & Supplies Store Automobile Quick Lubrication Services Automobile Repair or Service Shop Automobile Storage Car than self-service Car Wash—self-service Convenience Store/Gasoline Station—full service—with service/repair shop Convenience Store/Gasoline Station—self and full service combined—with service/repair shop Convenience Store/Gasoline service/repair shop (refer to Grocery/Convenience Store Program) Gasoline Station—full service—with service/repair shop Gasoline Station—self and full service combined—with service/repair shop Gasoline Station—self-service—without convenience and no service/repair shop Mobile Repair/Detailing Parking—public—not open air Parking—public—open air Roadside Assistance Tire Dealer Other (describe): 3. Inspection Contact Person: Telephone: 4. Does applicant have any vehicle dealer operations? Yes No 5. Does applicant have other business ventures for which coverage is not requested? Yes No