Business Name Contact Name Address: City: State: Zip Code: Email Address: Describe Operations Individual Partnership Corporation Other DESCRIPTION OF OPERATIONS Estimated Recovery Service Income # of Recoveries for a 12 month period # of Recoveries by Key Start (Drive Away) # of Recoveries by Tow Describe other services provided NONE Body Shop of Vehicles Sales of Automotive Parts Used Car Sales Leased Auto Sales Tires Sales Recap Tire Sales Do you have a written policy regarding firearms? Do you have a formal policy for hostile debtor? Total Staff Do you provide services as a sub-contractor for other tow truck operators or recovery agents? COVERAGES - Choose Your Limits Liability $1000000/$3000000 Liability $2000000/$4000000   Drive Away Limit $1000000   GarageKeepers Limit $375000 GarageKeepers Limit $500000 GarageKeepers Limit $1000000   On-Hook Limit $75000 On-Hook Limit $100000 On-Hook Limit $250000 On-Hook Limit $500000 Other   Deductible - $1000 Deductible - $2500   VEHICLES Vehicle #1 (VIN GVW Cost) Vehicle #2 (VIN GVW Cost) Vehicle #3 (VIN GVW Cost) Vehicle #4 (VIN GVW Cost) Additional Vehicles (Please email list of vehicles including VIN # GVW and Cost)   DRIVERS List All Drivers - Provide us with D.O.B. Driver Licenses and Years Experience Describe Loss History (We require loss runs for firm quote) Are filings required? If Yes please provide? (ICC name/address MC # PUC - name/address) How many plates do you have issued? (Dealer Transportation Repossessor Other) How many Drive Away's a year are performed? WHAT WE REQUIRE 4 Year Loss Runs Full Driver List (including years experience) Vehicle List (including Vin #'s GVW Stated Amount) Do not enter anything in this field: