To submit an Auto or Truck service center or gas station account for quotation, you must be an authorized agent of AutoServiceGuard. However, if you're an authorized agent or not and would like to know if we will be able to help you on an account, please fill out the "AutoServiceGuard QuickSumbit Form" below. One of our representatives will contact you within 2 business days to let you know if we'll be able to help you with this account.

This is intended to serve only as an indicator that the account may qualify for AutoServiceGuard. A full submission is required in order to properly evaluate the account, and, if it meets the underwriting guidelines and eligibility criteria, to release a quote proposal.

IMPORTANT: Please note that AutoServiceGuard for Auto and Truck Service Centers has a $5,000 minimum premium. Usually this would be a dealer with more than 5 employees.

Fields marked with an asterisk (*) are required and must be filled in before submitting the form.

Your Information

*Your Name:
*Your Agency's Name:
*Address:
*City:
*State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*ZIP:
* Phone:
Fax:
* Email:

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How did you hear about us?

* Select one of the following:
TargetPrograms.com
ProgramBusiness.com
IMMS.com
Insurance IQ
Internet search - please specify what site:
Referral - specify from who:
Other - please specify:

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Account's Information

Name of Service Center:
*Address:
*City:
*State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*ZIP:
* Number of Employees:
* Gross Sales:
* Is this a new venture?	Yes No
Describe the operations of this Serivce Center:

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Additional Information

* Who is the current carrier?
* What is the estimated current premium not including Workers Compensation premium?
* When does it expire?
* Does the insured offer towing services for cars or trucks other than their service customer's vehicles (i.e. - AAA, Police rotation.)
Yes No Don't Know
If yes, how many tow trucks do they have?
If yes, what % of their total sales is towing?
If yes, do they have any significant towing losses?
* How much loss information do you have on this account?: None Less than 3 years 3 to 5 years
* Please characterize their losses over last 5 years: None Very light Frequent but not severe Severe but not Frequent Frequent and severe Don't know
What is total insured property value?
Are they happy with their current carrier?
Why would they leave their current carrier?
*Is this your agency's renewal?	Yes No
If so, how long have you written this account and why are you moving it?
* How much premium for Auto or Truck service centers and gas stations do you currently write in your agency?
* How much premium for new Auto or Truck dealerships do you currently write in your agency?
Other information you would like to provide:

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