APPLICATION FOR GARAGE POLICY - Interstate …

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MSA010 (07/1 7) Page 1 of 5 APPLICATION FOR GARAGE POLICY Agent Name: ______________________________________ Retailer: ________________________________________ _ Agent # ______________________________________ Address: ________________________________________ _ Address: ______________________________________ ________________________________________ _ ______________________________________ Agent Phone # _____________________________________ Proposed effective date: _______/_______/_______ to _______/_______/_______ Business Entity: Applicant Name: ______________________________/dba______ _____________________ Individual Joint Venture Mailing Address: ________________________________________ __________ Partnership Corporation City: _________________________________ State: _____ Zip: ___________ Other:_____________________ Insured Contact: _________________

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 …

  Policy, Applications, Garage, Application for garage policy