NSB/NAI Quick On-Line Garage Quote Form 

This Form may be used Three ways:

1. (Preferred Method) Fill-out form on-line and "Submit" the form via email at the bottom of the page.
2. Fill-out form on-line, print and FAX using a conventional Fax machine.
FAX TO:1-501-843-4365p
3. Fill-out form on-line, drop your Internet connection with the form visible and FAX using your Printers FAX option. FAX TO:1-501-843-4365

General Information
Agency:            
Agent's Name:      
Agent's Phone No:  
Agent's FAX:       
Agent's Email:     
Quote Needed By:   
Insured Name:  
DBA Name:      
Physical Location: 
City:             County:   
State:             
Inside City Limits: Yes  No
No. of Locations:  
New Venture?:       Yes  No
If Yes, Years of exp:
Years in business:   
Prior carrier for the past three years:

Losses in the past 3 years including - date, description and amount paid.
If coverage is cancelled or non-renewed in the past 3 years please give details.

Description of operations
Sales:                            Yes  No           Repair:  Yes  No
Private passanger: Yes  No     Other: Yes  No
If other than private passanger, need description of units sold/repaired.

Number of vechicles sold annually:   
Percentage of salvage titled vechicles sold: %
If doing repairs give percentages of:
Cosmetic:   %   Mechanical: %
Structural: %   Frame:      %
UL approved paint booth?:  Yes  No
Salvage Operation ?:  Yes  No
Is salvage yard fenced?:   Yes  No
Do they do repo work?:     Yes  No
Number of dealer tags:    
Radius:                   
Garage liability limit:   
UM:                       
Med pay:                  
Dealers open lot limits:  
Dealers open lot ded:     
Max value any one unit:   
Avg value any one unit:   
Max number of unit:       
Avg number of unit:       
Is lot fenced?:            Yes  No
If so, describe fence:    
Garagekeeper legal limit: 
Garagekeeper legal ded:   
Max value any one unit:   
Avg value any one unit:   
Max number of unit:       
Avg number of unit:       

Employee Information:
Emp.1 Name:  Age:
Job Duties: 
CDL Lic:     Yes  No
MVR Violations: 
Furnished Auto?: Yes  No
 

Emp.2 Name:  Age:
Job Duties: 
CDL Lic-2:   Yes  No
MVR Violations: 
Furnished Auto?: Yes  No
 

Emp.3 Name:  Age:
Job Duties: 
CDL Lic:     Yes  No
MVR Violations: 
Furnished Auto?: Yes  No
 

Emp.4 Name:  Age:
Job Duties: 
CDL Lic:     Yes  No
MVR Violations: 
Furnished Auto?: Yes  No

Service Vehicles:
No.1...Year:      Make: Model: Radius: GVW:
Stated Value: VIT/DED:
 

No.2...Year:      Make: Model: Radius: GVW:
Stated Value: VIT/DED:

Property Information:
Bldg 1 Limit:      
Contents Limit:    
Construction Type: 
Protection Class:  
Square Footage:    
C.S. Alarm:         Yes  No
Age of Building:   
If building is 20yrs + provide updates to building :   
Wiring:            
Roof:              
Plumbing:          

Bldg 2 Limit:      
Contents Limit:    
Construction Type: 
Protection Class:  
Square Footage:    
C.S. Alarm:         Yes  No
Age of Building:   
Wiring:            
Roof:              
Plumbing:          


General Comments:

IMPORTANT: PLEASE PRINT THIS FORM FOR YOUR RECORDS BEFORE SUBMITTING.