APPLICATION FOR GARAGE POLICY

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Godwin Stevens
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1 APPLICATION FOR GARAGE POLICY Agent Name: Retailer: Agent # Address: Location: Phone # Proposed effective date: / / to / /. Business Entity: Applicant Name: Individual Joint Venture Mailing Address: Partnership Corporation City: State: Zip: Web Site: Inspection Contact: Years in business: Years Experience in this field: Contact Phone #: Location 1 Address: City: State Zip Location 2 Address: City: State Zip Location 3 Address: City: State Zip Description of Operations: INSURANCE HISTORY No prior insurance. No prior losses. Current Carrier Prior Carrier Prior Carrier Eff Date / / Exp Date / / Premium Eff Date / / Exp Date / / Premium Eff Date / / Exp Date / / Premium Date of loss / / Amount Description of Loss Driver Date of loss / / Amount Description of Loss Driver Date of loss / / Amount Description of Loss Driver TYPES OF AUTOS SOLD/ REPAIRED Sales Repair Sales Repair Auto Private Passenger New Golf Carts Auto Private Passenger Used Heavy Truck (26,000+ GVW) * Antique or Classic Autos Kit Car ATV, Snowmobile, Dirt Bike * Mobile Home Boat or Watercraft * Motorcycle or Scooter * Jet Ski * Semi- Trailer * Buses / Motor Coaches * Sports or High Performance Contractors Equipment * RV & Camper (Motorhome) * Emergency Vehicles or Public Livery * Trailer (Utility or Travel Trailer) Farm Tractors, Implements or Equipment * * SPECIALTY VEHICLE SUPPLEMENTAL REQUIRED MSA010 (01/14) Page 1 of 4

2 DOES RISK Yes No Yes No Sell, install or calibrate breathalyzer /ignition interlock systems? Park autos on public streets? Structurally alter or convert vehicles from factory design? Engage in auto or title pawning? Install lift kits? If yes, how high? inches Engage in towing for hire? Own, repair, service or sponsor a race car? Engage in repossession? Sponsor sports, racing, rides, rallies, shows, clubs, etc.? Engage in fuel conversion? Sell autos with a salvage title? If yes, of operation Rebuild or repair salvage titled autos? Sell used parts? Receipts: $ ( - provide details below) Dismantle autos or have salvage operations? Engage in other operations? If Salvage Yard: Are autos stacked more than 3 high? Have animals on premises? Is there a car crusher on site? Have weapons on person/ premises? Obtain certificates of insurance from all sub-contractors? Are keys secured in a lock box? Explain all yes answers: Loan, lease or rent autos to others? If yes: Loan/ Rent to customer while their auto is being repaired Rent/ Lease to the public Sell gasoline, diesel fuel, LPG, LNG, Kerosene, fuel oil (circle)? If yes, provide type & receipts:. Pick up and/or deliver customers vehicles? If yes, how far do you go? How many times a week? How do you transport autos: Owned Tow Truck or Car Hauler Owned Tow Bar or Dolly Driven by Employees Contracted Tow Truck or Car Hauler Temporary or Contract Driver DEALER OPERATIONS Sales mix: Retail Wholesale Consigned Internet Auction (risk is an auction). Buy here/ pay here sales? Yes No If yes, is the title transferred at the beginning of the finance period? Yes No Do salespeople accompany customers on all test drives? Yes No Allow extended or overnight test drives? Yes No Radius of pickup and delivery: None miles miles 501-1,000 miles Unlimited NON-DEALER OPERATONS Alarm, Stereo or Navigational Systems Hitch Sales or Installation. Bolt/ Weld (circle) Alignment Impound Yard Auto Dismantling (see used parts) Lift Kits / Lowering Kits Auto Body Shop/Painting Oil /Lube Auto Parts (uninstalled) Receipts Parking Lot & Parking Garage (self-park) Brakes Performance Enhancement Butane, Propane, LPG, LNG, Nitrous (circle) Tire Sales New Car Wash Full Service Tire Sales & Repair Used Convenience Store Receipts Trailer Hitch Install or Repair Detailing Valet Parking (Valet supplemental required) Driveaway Contractor, Wrecker or Towing (circle) Van Conversion Frame or Unibody Straightening Window Tinting Gasoline Station Full or Self Service (circle) Windshield Install or Repair General Engine Repair Are all spray painting operations completed in an UL approved booth? Yes No Are all paints and solvents stored in a fire resistive cabinet outside the paint booth? Yes No MSA010 (01/14) Page 2 of 4

3 AUTO STORAGE AND VALUES Owned Autos: Non-Owned Autos:. How are Autos Stored? How are Autos Stored? Building Standard Lot* Building Standard Lot* Non-Standard Lot ** Unprotected Lot ** Non-Standard Lot** Unprotected Lot** Value Per Auto: Average Max Value Per Auto: Average Max Number of Autos: Average Max Number of Autos: Average Max * Standard Lot: When closed for business all entrances, exits, openings and the entire premises is protected by fences with locked gates, or post and heavy chains with locks. ** Non-Standard Lot: Any other type of protection. ** Unprotected Lot: No theft barrier present. EMPLOYEE AND NON-EMPLOYEE INFORMATION Name Drivers License Number & State LIST ALL OWNERS, EMPLOYEES, DRIVERS & HOUSEHOLD MEMBERS Date of Birth 1 / / 2 / / 3 / / 4 / / 5 / / 6 / / 7 / / 8 / / 9 / / 10 / / Within the past 3 yrs. Violations Accidents Status Regular operator, Other employee, Non-Employee, Contract driver Have all owners, employees, drivers & household members been disclosed above? Yes No Gross Sales- Per $ 1,000/Sales: Payroll Per $ 1,000/Pay: Hours Worked Full Time / Part Time STATUS: USAGE: A) Regular Operator: Owners, partners, officers, salespersons, managers & employee with regular operation F) Furnished B) Other employees: Clerical staff, lot personnel, mechanics & those who do not regularly operate an auto. B) Business Use C) Non-employees: Inactive owners, partners, officers and their spouses. N) None D) Contract driver: Scheduled individual (provide name) or Blanket. Auto Usage Furnished, Business, None SCHEDULED AUTOS Use: P = Personal S = Service (used to service the risk itself) C = Commercial (tow truck for hire) Year Make Model VIN Value Loss Payee GVW Use Radius Filings Required Check Coverages Desired 1 Federal State Liab SCL & Coll / Comp & Coll Med Pay UM/UIM PIP 2 Federal State Liab SCL & Coll / Comp & Coll Med Pay UM/UIM PIP 3 Federal State Liab SCL & Coll / Comp & Coll Med Pay UM/UIM PIP MSA010 (01/14) Page 3 of 4

4 COVERAGE & LIMITS Garage Liability Limit of Liability Deductible Auto Each Accident Bi & PD Other Than Auto Each Accident Other Than Auto Aggregate Limit Garagekeepers Limit of Coverage Legal Liability Location 1 Maximum Value Per Single Auto Direct Excess Location 2 Deductible Per Auto Direct Primary Location 3 Deductible Per Occurrence Comprehensive & Collision In- Tow Coverage: For Hire Not-For-Hire Specified Causes & Collision Limit Per Tow Truck: Number of Tow Trucks Dealers Open Lot Limit of Coverage Comprehensive & Collision Location 1 Maximum Value Per Single Auto Specified Causes & Collision Location 2 Deductible Per Auto Location 3 Deductible Per Occurrence False Pretense Your interest in covered autos you own Consigned Autos Your interest and the interest of any creditor as Loss Payee Medical Payments Auto Medical Garage Operations /Premises Medical Uninsured Motorists Each Accident Number of Dealer Tags: Underinsured Motorists Each Accident Uninsured Motorists Property Damage Personal Injury Protection Per Statute Radius of Pickup & Delivery None Miles Miles 501-1,000 Miles 1,000+ Miles Broadened Coverage (includes Personal Injury and $ 50,000 in Fire Legal Liability) Hired Auto Fire Legal Liability Limit Broad Form Products Personal Injury Liability Additional Insured Waiver of Subrogation (landlord only) Drive Other Car Name Address: Insurable Interest/ Relationship to risk: Additional Information (Include any Related GL Operations you wish to package with the Garage Policy) : 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. 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 and no material facts have been suppressed or misstated. / Signature of Agent Date Signature of Applicant MSA010 (01/14) Page 4 of 4

5 SPECIALTY VEHICLE SUPPLEMENTAL APPLICATION Applicant Name: Operations: Dealer Non-Dealer TYPES OF VEHICLES Private Passenger Autos and Light Trucks Mobile Homes Cruiser / Touring styled Motorcycles (ie. Harley Davidson) Recreational Vehicles / Motor Homes Sport / Speed styled Motorcycles (ie. Buell, Ducati, CBR) Travel Trailers / Campers / 5 th Wheel Moped, Goped, Scooters (must be street legal) Utility Trailers/ Service Trailers / Horse Trailers (circle) (max load capacity is 2,000 lbs) Dirt Bikes / Motocross cycles Semi Trailers / Livestock Trailers ATV s (3 wheel, 4 wheel, or other off road vehicles) Tanker Trailers / Tankers Snowmobile Heavy Truck (26,001 45,000 GVW) Logging Equipment / Logging Trucks list work performed:. Contractors Equipment / Dump Truck list types here:. Farm Tractor, Equipment or Implements list types here:. Bus: School bus Public Transport Passenger Capacity: Extra Heavy Truck (over 45,001 GVW) Bucket Truck / Cherry Picker / Vehicle with a man lift Is man lift repaired/ serviced by risk? Yes No Are lifting apparatus hydraulics serviced? Yes No Crane Is lift repaired/ serviced by risk? Yes No Are lifting apparatus hydraulics serviced? Yes No Boat / Watercraft - other than jet ski Any Water or Marina Exposure? Yes No Hull Repair. Jet Ski / Personal Watercraft OPERATIONS: Yes No Welding If yes, what is welded: Yes No Hydraulic Work If yes, what does the hydraulic operate: Yes No Structural Alterations If yes, describe: Yes No Parts Manufacturing If yes, describe: Yes No Manufacturing / Fabrication (other than parts) If yes, describe: Yes No Tanker Sales / Repair If yes, interior cleaning or repair? Yes No Exterior clean/repair? Yes No Yes No Refrigerated Truck or Trailer Sales / Repair If yes, of your operations Yes No Custom Auto Assembly / Bike Building (Pre-manufactured frame & parts) Yes No Custom Motorcycle Building / Manufacturing (parts manufactured by the risk) Yes No Storage or Parking Space Rental If yes, receipts: Yes No Are autos taken to Trade Shows, Fairs or Special Events? If yes, how many per year? Annual Receipts for: Accessory sales $ Uninstalled Parts sales $ Grocery & Supplies $ Locations where operations are conducted: Your Premises Customer Premises Roadside Additional Information: This questionnaire does not bind the Application nor the Company to complete the insurance, but it is agreed that the information contained herein shall be part of the basis of the contract should a policy be issued. By signing you are hereby certifying that all information is accurate to the best of your knowledge. / Signature of Agent Date Signature of Applicant MSA020 (01/14)

6 VALET AND PARKING SUPPLEMENTAL APPLICATION Applicant Name: Loc Establishment Name & Address Information on parking Type of Establishment Hours & Days # Parking Spaces 1) 2) 3) 4) 5) * If yes, provide a map with secondary address, traffic route, and/or where cars are parked on street. What is the average value per vehicle? $. What is the maximum value per vehicle? $. Are you the owner of the premises? Yes No If yes, is Commercial General Liability coverage in place? Yes No Are keys secured in a locked cabinet or attended by an employee at all times? Yes No Do you use at least a 3 part ticket (Keys, Car & Customer)? Yes No Do you offer services for special events at locations not listed above? Yes No If yes, how many special events per year and describe locations.. This questionnaire does not bind the Application nor the Company to complete the insurance, but it is agreed that the information contained herein shall be part of the basis of the contract should a policy be issued. By signing you are hereby certifying that all information is accurate to the best of your knowledge. / Signature of Agent Date Signature of Applicant MSA023 (01/14)

PENNSYLVANIA MOTORCYCLE APPLICATION

W N TUSCANO AGENCY 950 Highland Ave. P.O. Box 1027 Greensburg, PA 15601 (800) 442-8063 Fax: (724) 838-1433 PENNSYLVANIA MOTORCYCLE APPLICATION BEST RATING A EFFECTIVE DATE EXPIRATION DATE (Must be submitted