Dealers Choice Application page

Travelers Affinity & Alternative Markets

The Dealer's Choice
Insurance Program

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Arthur J. Gallagher & Co.
Risk Management Services, Inc.
125 S. Wacker Dr., Suite 500
Chicago, IL 60606
Toll-Free: 1-866-628-2631
Fax: (312) 803-6359
Producer Code: XW786

Three Year Loss Required with each Application

GENERAL INFORMATION

Named Insured:
Mailing Address: City/State/Zip:
Legal Entity:	Individual Partnership Corporation
Effective Date:		Insured Phone #:
Billing:	25% down & 9 equal installments Contact Name:
Agency Use (Circle one.)	JA5(Conv. Store/no repair)) JA6(Operation with Repair) Solicitor Code:
1. # of years in business at this location:
2. Do you have a first aid medical plan in place at all locations?			Yes	No
3. Are there written safety guidelines in place at all locations?			Yes	No
4. Are regular safety meetings conducted at all locations? If yes, how often are they conducted?			Yes	No
5. What is the minimum number of attendants on duty, at any one time, at any location?
6. Are tanks dipped daily?			Yes	No
7. How often are bank deposits made? (Please explain "other".)			Daily	Other
8. How much are average deposits?			$
9. Who makes the deposits?

3 Year Loss Information: Property, Liability, Crime, Automobile, Workers Comp, & Umbrella
(Please attach hard copy loss runs from your insurance carriers.)

Loss Date	Loss Description	Paid	Reserved

PROPERTY/LIABILITY - Please complete where à is shown

þ	General Liability Limits: $1,000,000 occurrence / $2,000,000 aggregate	à	Property Deductible (please select one of the following) $500 $1,000 $2,500 $5,000
þ	Medical Payments: $5,000 each person	þ	Power Pac
þ	Property Damage Deductible: $0, except: $500 for operations car washes $1,000 for operations with repair	þ þ þ	Money & Securities Coverage – up to $25,000 Employee Dishonesty Coverage – up to $25,000 Business Income - 12 months actual loss sustained
þ þ à	XTEND Liability Pollution Exclusion Amendment Employee Benefits Liability Yes No	à	Hired & Non-owned Auto Liability Do you have business-owned vehicles? Yes No
à à	Garagekeepers Legal Liability: (select appropriate limit; for repair operations only) $30,000 $60,000 $75,000 $90,000 $120,000 $150,000 $180,000 Other Garagekeepers Legal Liability Deductibles: (select appropriate deductible) Comprehensive: $250 / $1,250 $500 / $2,500 Collision: þ $500

This application must be completed for each location.

Location # Specify Gas Sold at this location: BP Amoco ARCO Other:

d/b/a		Within 15 miles of coast? Yes No					# of Garage Bays: # of Fueling Stations:
Street Address:				City:		State:		Zip:
Building (specify replacement cost):	$			BPP – stock/store inventory:		$
Pumps, Canopies, Nozzles, Hoses:	$			Fuel Inventory @ 50%:
Tenant Glass - # of linear feet:				Full time employees:		Part time employees:
Sign value (within 1000 feet of building): $				Age of Building: If > 25 yrs, date of upgrade:
Annual sales/receipts (all operations) at this location:$					Annual sales/receipts gas sales only: $
CarWash? Yes No If yes, value of equip: $ Annual sales $			Propane Sold? Yes No If yes, annual sales $				Liquor Sold? Yes No If yes,annual sales $
Square feet of building:	Sole Occupant? Yes No If no, please list other occupants and sq. ft. they occupy:
Construction of Building:
Additional Insureds: (Please describe relationship of any additional insured requested.)
Name & address of Franchisor:
Name & address of Landlord:
Name & address of other insured:
The # of fueling stations or # of autos you can accommodate, if everyone fueled at one time?

Location Information (All questions must be completed for each location.)

1. What are the hours of operations at this location?
2. Do all pumps have splash guards?	Yes	No
3. Is access to the inside of the store limited after 11:00pm?	Yes	No
4. Do you have a drop safe at this location?	Yes	No
5. Does this location have a central station alarm?	Yes	No
6. Specify type of car wash at this location	Full Service	Self-Serv.
7. Is propane sold at this location? If yes, do you: Exchange Bottles? Fill Bottles? If you fill propane bottles, are employees trained to do this? Describe how propane is separated from other operations:	Yes Yes	No No
8. Do you allow or keep firearms at this location?	Yes	No
9. Do you provide personal protective equipment, allow or keep guard dogs on premises?	Yes	No
10. If this location includes repair or service operations, Is the public permitted in the service area? Do you have key control procedures for customer vehicles left in your care?	Yes Yes	No No
11. Please indicate the total annual receipts at this location: $ Please provide the following breakdowns of annual receipts for: Gas Sales: $ Convenience Store Sales:$ Repair Sales: $ Car Wash Sales: $ Propane Sales:$ Liquor Sales: $ Restaurant Sales: $ (if applicable)

PROPERTY/LIABILITY

OPTIONAL COVERAGES
	Small Computer	$20,000 Limit
	Spoilage	Limit needed:
	Energy Equipment Endorsement	Have boilers? Yes No
	Liquor Legal Liability (limit follows general liability limit)		Annual Sales: $
	Sign Coverage (for signs over 1000 feet from building)		Limit:
	Motor Vehicle Damage to Leased Buildings (limit: $25,000)
	Flood Coverage up to $100,000 limit per location.		FLOOD ZONE:
	Earthquake Coverage up to $100,000 policy limit
Please describe any other coverage and limits you need: (Program Manager may call to discuss prior to quoting.)

AUTOMOBILE

POLICY COVERAGES and limits (unless otherwise specified)
Symbol	Coverage	" þ " if desired	Optional Coverages
1	Liability - $1,000,000 CSL		Comprehensive - $500 deductible minimum
5	PIP – Statutory limit		Collision - $500 deductible minimum
7	Med Pay - $5,000 per person		Towing – For Private Passenger Vehicles Only
2	Uninsured Motorists – CSL limit		Rental Reimbursement
2	Underinsured Motorists – CSL limit		Non-owned & hired coverage

Automobile Information Please answer all of the following questions if you have owned autos to be insured.

1. Are all vehicles titled in the business name?	Yes	No
2. Are all vehicles used in the course of business? If no, how are they being used?	Yes	No
3. Do you require certificates of insurance from all employees using their own vehicles in the course of business? Do these certificates show that the employee has at least $100,000 of liability coverage?	Yes Yes	No No
4. Do you own any tow trucks? If yes, what are your annual towing receipts? $ If yes, do you have any contracts with municipalities or other entities? If yes, please explain the nature of the contract:	Yes	No
5. Have any drivers had any of the following violations? License suspended or revoked, or driving without a license? Driving while intoxicated or impaired? Reckless driving, or speed in excess of 25 miles over the posted limit? Criminal type convictions (e.g., negl. homicide, manslaughter, hit & run, etc.) Failure to report an accident or making a false report to authorities Three or more at fault accidents and/or moving violations in the past 3 years Two or more at fault accidents and/or moving violations in the past 12 months (Please explain any yes responses.)	Yes Yes Yes Yes Yes Yes Yes Yes	No No No No No No No No

Driver Information Please list all drivers, including employees using their own vehicles for business purposes.

Driver Name	Date of birth	License Number	Issuance State

Vehicle #1

Vehicle Year	Vehicle Make	Vehicle Model	Comp/Coll Ded ($500/$500 min.)	Cost New	VIN
Garaging Location (street address, City, State, ZIP)
Vehicle Usage		Vehicle Weight		Additional Coverages:
Commercial		0-10,000 lbs		Rental Reimbursement $ per day / days
Private Passenger		10,001-20,000 lbs		Towing (private passenger use only)
		20,001- 45,000 lbs
Loss Payee (name/address):
Additional Insured: (Please specify relationship.)

WORKERS COMPENSATION
(Please answer all of the following)

Please answer all of the following questions if Workers Comp coverage is requested.
1. Do you lease any employees from other entities?	Yes	No
2. Do you lease any employees to other entities?	Yes	No

Employers Liability BI Limits $100,000 each accident / $500,000 policy limit / $100,000 each employee
$500,000 each accident / $500,000 policy limit / $500,000 each employee
$1,000,000 each accident / $1,000,000 policy limit / $1,000,000 each employee

Coverage State

Most Common Classification Codes

Annual Payroll

8006 – Convenience Store $

8381 – Convenience Store where gas is 90%+ of sales $

8810 - Clerical $

8380 - Automobile Service or Repair $

$

$

Experience Mod: Federal ID # (FEIN):

Bureau ID #:

COVERAGE INCLUSIONS/EXCLUSIONS

Name: Title: Include Exclude

Name: Title: Include Exclude

Name: Title: Include Exclude

Name: Title: Include Exclude

UMBRELLA SECTION

SIR: $5,000
(CT & NY = $10,000; CA = $0)

$1,000,000 Limit
Other Limit Requested: $

Please read the statement applicable to your state and the final statement.
Then sign, date and return with your application.
(Click below to expand the FRAUD STATEMENT)

FRAUD STATEMENT

Underwriting Information
BP/Amoco/Arco Dealers Insurance

	CALIFORNIA: In addition, any person who knowingly makes an application for motor vehicle insurance coverage containing any statement that the applicant resides or is domiciled in this state when, in fact, that applicant resides or is domiciled in a state other than this state, is subject to criminal and civil penalties.
	COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
	DISTRICT OF COLUMBIA: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
	FLORIDA: Any person who knowingly and with intent to injure, defraud, or decieve any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
	MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
	MASSACHUSETTS: NOTICE: If you or someone else on your behalf gives us false, deceptive, misleading or incomplete information in this application and if such false, deceptive, misleading or incomplete information increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance Parts and we may cancel your policy. Such information includes the description and the place of garaging of the vehicle(s) to be insured, the names of operators required to be listed and the answers to questions in this application about all listed operators. Check to make certain that you have correctly listed all operators and the completeness of their previous driving records. The Merit Rating Board may verify the accuracy of the previous driving records of all listed operators, including that of the applicant for this insurance.
	MICHIGAN: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00.
	MINNESOTA: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
	NEW YORK: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
	OHIO: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
	OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
	OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law.
	PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
	RHODE ISLAND: In Rhode Island this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? YES NO
	UTAH: For your protection, Utah law requires the following to be included in this application: "Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison."
	VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
	WISCONSIN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
	ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
Signature of Applicant: Date:

(Click below to expand for Supplemental Application)
(This section is required if more than 1 Owned Vehicle)

Supplemental Application

Underwriting Information
BP/Amoco/Arco Dealers Insurance

Vehicle #1

Vehicle Year	Vehicle Make	Vehicle Model	Comp/Coll Ded ($500/$500 min.)	Cost New	VIN
Garaging Location (street address, City, State, ZIP)
Vehicle Usage		Vehicle Weight		Additional Coverages:
Commercial		0-10,000 lbs		Rental Reimbursement $ per day / days
Private Passenger		10,001-20,000 lbs		Towing (private passenger use only)
		20,001- 45,000 lbs
Loss Payee (name/address):
Additional Insured: (Please specify relationship.)

Vehicle #2

Vehicle Year	Vehicle Make	Vehicle Model	Comp/Coll Ded ($500/$500 min.)	Cost New	VIN
Garaging Location (street address, City, State, ZIP)
Vehicle Usage		Vehicle Weight		Additional Coverages:
Commercial		0-10,000 lbs		Rental Reimbursement $ per day / days
Private Passenger		10,001-20,000 lbs		Towing (private passenger use only)
		20,001- 45,000 lbs
Loss Payee (name/address):
Additional Insured: (Please specify relationship.)

Vehicle #3

Vehicle Year	Vehicle Make	Vehicle Model	Comp/Coll Ded ($500/$500 min.)	Cost New	VIN
Garaging Location (street address, City, State, ZIP)
Vehicle Usage		Vehicle Weight		Additional Coverages:
Commercial		0-10,000 lbs		Rental Reimbursement $ per day / days
Private Passenger		10,001-20,000 lbs		Towing (private passenger use only)
		20,001- 45,000 lbs
Loss Payee (name/address):
Additional Insured: (Please specify relationship.)

(Click below to expand for Supplemental Application)
(This section is required if Operations include Liquor Sales or Restaurant Operations)

Supplemental Application

Underwriting Information
BP/Amoco/Arco Dealers Insurance

Liquor Information

Please answer all of the following questions if you sell liquor at any location:
1. Have you ever had a liquor liability claim? If yes, please explain:	Yes	No
2. Has your liquor license ever been suspended or revoked? If yes, please explain:	Yes	No
3. Is training provided to employees regarding the sales of liquor? Please describe:	Yes	No
4. Are there written and posted instructions on how to handle suspected intoxicated customers? Are there written and posted instructions on how to handle minor customers? If no, please explain:	Yes Yes	No No
5. Are signs displayed on premises prohibiting the on-premises consumption of liquor?	Yes	No
6. Please describe the record or report procedures kept regarding liquor incidents, including calling police:

Restaurant Information

Please answer all of the following questions if there is a restaurant operation in any location:
1. What type of restaurant is in this location? What is the franchise name or what type of food is served? Seating Capacity
2. Are there deep fat fryers?	Yes	No
3. Do you own and operate this restaurant? If no, do you require certificates of insurance from the tenant? Are you listed as an additional insured on their policy? Comments:	Yes Yes Yes	No No No
4. Are hoods,ducts, grease filters, and surface cooking equipment(including deep fat fryers) protected by a UL listed automatic fire extinguishing system? Comments:	Yes	No
5. Is the automatic fire extinguishing system serviced at least every 6 months? Comments:	Yes	No

I HEREBY DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The signing of this application does not bind the applicant or Travelers to complete this insurance.

(Agent) (Date) (Applicant/Title) (Date)