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www.usgins.com USG

USGI nsurance Services, ApplicationALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE : USG Insurance Services, :Location:Contact Name:Phone Number:Insured Name:Proposed Policy PeriodtoLocation #1 Location #2 ** List all additional locations on a separate sheet of paper. **IndividualPartnershipJoint VentureCorporationOtherInspection and Audit Contact / Phone NumberYears in businessDescription of Operations and ExposureNATURE OF BUSINESSD ealer: Wholesale Retail Non-Franchised Franchised withNon-Dealer: Repair Shop Gas Station Parking Facility OtherUNDERWRITING INFORMATIONDO YOU: YES NO1.

USG Insurance Services, Inc. www.usgins.com Garage Application ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT. Broker: USG Insurance Services, Inc. …

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