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Wreckers, Roll Backs, Tow Trucks, etc.
 

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(RRequired by BTRO Regulations)
 

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Virginia Garagekeepers
Insurance Quote Form
Please take a couple of minutes to complete the form.
Your Information:

* denotes required fields

*Name:
*Business Name:
*Street Address:
*City:
*State:
*Zip:
*E-Mail:
*Confirm E-Mail:
*Phone:
Fax:
Business Type: Corporation
Partnership
Individual
Other

 

Currently insured?
(If yes, list carrier, and Policy Dates.
If none, leave blank)
 
Current premium (cost) $
 
List claims & amounts paid
During last 5 years
(If none, leave blank)
 
Policy form:
 Claims Made    Occurrence
 
Retroactive date (if any):
 
Years in business:
 
DOT Shop Identification
Code(s) Number:
 



 
Underwriting Information:
 
Describe
your business operations:
 
 
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0): Insert # of
Employees here:
 
Location & Sales Information:
Insert Annual Gross Revenues from this operation here: Square Footage of office or business location:
 
Type of Building (wood frame, concrete, etc.): Number of Stories:
 
Are there other business/residences in this building (describe)?: Describe safety features (alarm, sprinklers, fire protection, etc):
Provide breakdown percentages of work provided:
Passenger %  Truck %  Off-the-Road %
 
Coverage Desired:
Policy Type interested in:
Claims Made Form
Occurrence Form

Limits of liability coverage interested in:
$250,000
$500,000
$1 Million
$5 Million
Limit of business property needed:
$

Limit of Garagekeepers Coverage Needed:
(Total amount of vehicle left in your possession.)
 $
NOTE: Don't worry if you are not sure about coverage type. We will suggest the best coverage for you! (We will contact you if we need more information.)
 
 
Send my quote via: E-Mail Fax USPS Phone

 
Thank you for completing this form!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please send my
garage/auto repair shop quote now!


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5400 Whiteside Road, PO Box 308, Sandston, VA 23150-0308
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