APPLICATION FOR GARAGE POLICY

Applicant Name: Top Notch wrecker& /dba Agent:

Mailing Address: 4445 E benson hwy 85706 Address:

Phone Number: 5203395217 Contact Name Travis Edwards _ Website

Proposed effective date: / / to / / Business Entity:
Years in business: 3 Years of Experience in this field: 27 Individual Joint Venture
If New Venture, describe experience: have been heavy diesile mechanic for 23 Partnership Corporation
Description of Operations: heavy diesel repair ✔ Other:LLC
Locations: ✔ Same as Mailing Address
1) Address: City: State Zip
2) Address: City: State Zip
3) Address: City: State Zip

List any other business operations operated by you:

INSURANCE HISTORY No prior insurance

Current Carrier Eff Date / / Exp Date / / Premium
Prior Carrier Crest Insurance Group Eff Date 3/14/2023
/ / Exp Date 3 / 14 / Premium $9,538.78
2024
Prior Carrier Eff Date / / Exp Date / / Premium
In the last 3 years has any company cancelled, declined or refused to issue similar insurance to the insured? Yes x No
If yes, explain:
LOSS HISTORY No prior losses
Loss Year Amount Description Driver
Loss Year Amount Description Driver
Loss Year Amount Description Driver

AUTO EXPOSURE
0
Auto – Used Private Passenger, Light Trucks % Golf Carts – Off Road Use %
0 100
Auto Auction (held on your premises) % *Heavy Truck (26,000 GVW) %
0
Antique or Classic Auto % High Performance or Race Car %
0
ATV, Snowmobile, Dirt Bike % Mobile Home or Tiny Home %
0
*Boat or Jet Ski % *Motorcycle or Scooter %
0
*Bus % Off Road 4x4 %
Camper or Travel Trailer % *RV, Camper or Motor Coach %
Emergency Vehicles % *Semi-Trailer %
*Equipment – Contractors, Farm, Lawn % Trailer (Utility or Livestock) %
Golf Carts – Licensed for Road Use % *Valet Parking %
Other: _ %

*Complete SUPPLEMENT

MSA010 (04/21) Page 1 of 6

DO YOU:
Obtain certificates of insurance from all sub-contractors? ✔
Yes No Have weapons on person/ premises? Yes ✔
No
Loan, lease or rent autos to others? Yes ✔
No Have animals on premises? Yes ✔
No
If yes: Loan/ Rent to customer while repairing their auto Rent/ Lease to the public Rental/Loaner Agreement in place
Explain all yes answers:

DEALER OPERATIONS
Nature of Business:
Broker % Import % *Salvage / Reconstructed Titled Autos %
Consignment % Internet % *Wholesale %
Export % Retail % *Complete Supplement

Vehicles sold per year

Number of Dealer Plates Number and type of any other plates:
List all states where you conduct business:
Who transports your vehicles? Driven by Owner/Employees Temporary or Contract Driver Owned Tow Bar or Dolly
Owned Tow Truck or Car Hauler Contracted Tow Truck or Car Hauler
DO YOU:
Accompany customers on all test drives? Yes No
If no, do you:
Allow extended or overnight test drives? Yes No
Require a copy of their Driver’s License & Proof of Insurance? Yes No
Accompany anyone under age 21? Yes No
Offer Buy-Here / Pay-Here Sales, Rent-to-Own, Lease-to-Own, or in-house financing? Yes No
If yes, do you:
Transfer title to the customer as lienholder and immediately report the sale to the state? Yes No

NON-DEALER OPERATIONS
Nature of Business: Repair on Premises 90 % Mobile Repair 10 %
DO YOU:
Allow customers to drive vehicles into the bay? Yes ✔ No
Park autos on public streets? Yes ✔ No
Have signs posted to keep customers from work areas? ✔
Yes No
Have No Smoking signs posted? ✔
Yes No
Have serviced and charged fire extinguishers on site? ✔ Yes No
Have Repair/Transporter plates? If yes, # Yes ✔ No
Pick-up or deliver customers’ vehicles? Yes ✔ No
If yes, how far do you go and how often? Miles Times a week
Sell any autos? Yes ✔ No
If yes, how many do you sell per year?
Have any other sales exposure? Yes ✔ No
If yes, provide:
Number of Gasoline Diesel Fuel LPG
gallons:
New Parts $ Used Parts $ Convenience Store $
Other: $

MSA010 (04/21) Page 2 of 6

NON-DEALER OPERATONS “Auto” refers to types of vehicles identified on page 1 *SUPPLEMENT REQUIRED

Alarm, Stereo or Navigational Systems 0% Gas Station Full Serve Self-Serve 0%

Alignment 0% Handicap Vehicle Conversion* 0%
Alarms, GPS, Radio/Stereo, Sirens 0% Impound / Storage Yard 0%
Airbags 0% Inspection Station 0%
Auto Dismantling 0% Lift / Lowering Kits Max # inches 0%
Auto Restoration Ground-Up? Yes ✔ No % Machine Shop 0%
Bedliner Installation 0% Oil /Lube 10 %
Body & Paint Shop 0% Parking Lot or Garage (self-park) 0%
Brakes 10 % Parts Sales (Uninstalled) 0%
Breathalyzer / Ignition Interlock 0% Pawn Shop – Auto and/or Title Pawn 0%
Car Wash Full Service Self Service 0% Roadside Assistance 10 %
Is there an automated car wash on premises? Yes ✔ No 24 Hr? ✔ Yes No Tires 5 %
If yes, who drives vehicles through? Customer Employee Salvage Operations*
Convenience Store % Salvage Titled Auto Repair /Rebuilding %
Cooking / Restaurant exposure? Yes ✔ No Salvage Yard %
Customization and/or Performance Enhancement % Suspension 10 %
Purpose: Speed Appearance Run Better Tires (If any, complete tire section below) 0%
Detailing (hand wash/detail only) % Trailer Hitch Install or Repair %
DIY Self Service Bay Rental % Bolt % Weld %
Engine Repair % Transmission 10 %
Fabrication / Machine Shop % Tune Ups / Maintenance 20 %
Fiberglass Body Repair % Window Tinting 0%
Frame Work: Straightening Yes No % Windshield Install or Repair 0%
Cutting/Stretching Yes No Wraps % 0Do
you cut between the axles? Yes No Wrecker For Hire Repo Yes ✔ No 0 %
Fuel Conversion (CNG, Nitrous) Type % Wrecker Not For Hire %

Are all spray painting operations completed in a separate, ventilated room? Yes No No Painting
Are all fiberglass resins, paints and solvents stored in a fire resistive cabinet? Yes No
Explain if No

TIRES and RIM REPAIR (Complete if any percentage of Tires above)

1) New Tires % Used Tires 6) Do you perform Rim Repair Yes No
2) Do you fix/change tires for heavy trucks? Yes No If yes: a) Are tires removed? Yes No
3) Do you sell Tires over 5 years old? Yes No b) Cosmetic Only? Yes No
4) Do you rent or lease Tires? Yes No
5) Describe quality assurance to ensure tires are properly installed & inflated and all lug nuts properly tightened:

AUTO STORAGE – DEALER AND NON-DEALER

Fully fenced and gated?
In Building Age: Construction: PC: Central Station Alarm? Yes No
Other
Do you store autos anywhere other than your lot? Yes No If yes, where?
Are keys left in or on any vehicles? Yes No
Are keys secured in a lock box? Yes No
If no, describe key controls:

MSA010 (04/21) Page 3 of 6

EMPLOYEE and NON-EMPLOYEE INFORMATION: ALL owners, employees, drivers and household members MUST be listed,
including contract drivers, 1099 and other employees who do not have their own insurance
PAP In
Loc Driver’s Date of Accidents/Violations Hours Status Auto
Name State Place?
# License # Birth (past 3 yrs.) Worked* ** Use ***
****
Travis Edwards D01649747 AZ 08/22/1984 N F 1 B Y

Blanket Contract Driver Exposure: Yes x No

MISSOURI ONLY: Anyone under the age of 21 must be listed on the MUS 70019 Driver Exclusion, with the insured’s signature.
*Hours Worked: ***Auto Use: ****PAP = Personal Auto Policy
F = Full-Time (over 20 hrs/week) A = Furnished a covered auto for personal use
P = Part-Time (20 or less hrs/week) B = Business Use only of covered autos
N – Non-Employee C = Excluded Driver
** Status:
1. Active owner, partner or officer 5. Mechanic 9. Spouse of any other person furnished an auto
2. Inactive owner, partner or officer 6. Clerical 10. Child of any other person furnished an auto
3. Lot person 7. Spouse of owner, partner or officer 11. Occasional or contract driver
4. Salesperson 8. Child of owner, partner or officer 12. Other:

COVERAGE & LIMITS

Garage Liability Deductible

Limit of Garage Liability Auto 1,000,000 /Other Than Auto 1,000,000 /Aggregate $2,000,000
Radius of Pickup & Delivery: x 1-300 miles 301-500 miles 501-1,000 miles Over 1,000 miles
Dealer’s Errors & Omissions ($50,000 Limit) Truth in Lending Federal Odometer Title Insurance Agents
Package Additional GL Operations:

Garagekeepers Limits of Coverage

Legal Liability x Comprehensive & Collision Location #1 Max Limit Per Vehicle
Direct Excess Specified Causes & Collision Location #2 $250,000
Direct Primary Deductible Location #3
In - Tow Coverage: For Hire Not-For-Hire Limit Per Tow Truck: Number of Tow Trucks
Dealers Physical Damage Limits of Coverage
Comprehensive & Collision Location 1 Max Limit Per Vehicle
Specified Causes & Collision Location 2
Deductible Location 3
False Pretense Coverage *Limit Calculation: Value Per Auto: Average Max
Number of Autos: Average Max
Coverage applies to: (Check at least 1)
x Your interest in covered autos you own Consigned Autos
Your interest and the interest of any creditor as Loss Payee (provide name/address below)

Loss Payee Name/Address:

(Dealers PD):

MSA010 (04/21) Page 4 of 6

 ADDITIONAL COVERAGE OPTIONS

Medical Payments Garage Operations /Premises Limit Auto Limit

Personal Injury Protection (limit per statute)

Uninsured Motorists Each Accident Limit Number of Plates: Dealer

Underinsured Motorists Each Accident Limit
Uninsured Motorists Property Damage Limit
I reject all Uninsured Motorists Coverages

Personal Injury Protection Limit Per Statute

Broadened Coverage (includes Personal Injury and $ 100,000 in Damage to Rented Premises)
Damage to Rented Premises Limit
Personal Injury Liability (do not select if Broadened Coverage is requested)
Hired Auto
Broad Form Products
Drive Other Car

ADDITIONAL INSURED OPTIONS

X Owner of Garage Premises (CA 2509)

_
Designated Insured (CA 2048)

Blanket Additional Insured

Grantor of Franchise (CA 2049)
_
Leased Equipment (CA 2047)
_
Waiver of Subrogation

Provide Insurable Interest/ Relationship to risk:

SCHEDULED AUTOS

Coverage(s): Liability X Comprehensive & Collision Specified Causes & Collision Deductible

Year Make Model VIN Value GVW Use Radius

2006 Chevrolet Silverado 1GCHK29U46E21860 $18,500 7000 RS 300
2005 TMCC Blackhawk 1T9C1L2665F717840 $10,000 1050 RS 300

2014 GMC Sierra 1GT121E89EF140622 $37,000 12,000 RS 300

30,000 RS/Tow 300

1986 Navistar Truck/Tractor 1HSLRTVN2GHA62076 $20,000

MSA010 (04/21) Page 5 of 6

 FRAUD STATEMENT
(Not applicable in the states mentioned below where a specific warning applies.)
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 may be
subject to civil and criminal penalties.
In AL, AR, AZ, DC, LA, MD, NM, RI & WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application
for insurance is guilty of a crime and may be subject to fines, (restitution in AL) or confinement in prison.
In 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 for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
In Florida and Oklahoma: Any person who knowingly, and with intent to injure, defraud, or deceive 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.
In Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with
knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any
written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for
personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning any fact
material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act.
In KY, NY, OH and PA: 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 such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value
of the claim for each such violation in NY).
In Maine, Tennessee, Virginia and Washington: 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 denial of insurance benefits.
In New Jersey: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines
and criminal penalties.
In 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.

I understand that misrepresentation or omission of material facts will be cause for cancellation and may void coverage. I
declare to the best of my knowledge that all statements herein are true, correct and complete to the best of my knowledge and
no material facts have been suppressed or misstated.

3/15/22
/
Signature of Agent Date Signature of Applicant

MSA010 (04/21) Page 6 of 6