www.usgins.com USG

1 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.

2 Engage in any other operations?2. Sponsor sporting or social events?3. Sponsor or own any race cars?4. Sponsor driver s education cars?5. Install, service or repair air bags? alter or convert vehicles from their original design? test driving of vehicles unaccompanied? YES NO8. Repossess vehicles for others?9. Engage in fuel conversion?10. Have guard dogs?11. Operate petroleum or LPG trucks?12. Engage in auto pawning?13. Sell vehicles with salvaged titles?14. Allow customers in the work area?

3 15. Rent, lease or load vehicles, machinery or equipment to others?Explain all YES responses:Insured Website:Insured Address:PLEASE INDICATE THE PERCENTAGE OF YOUR INVOLVEMENT IN THE FOLLOWING TYPE OF AUTOSS ales RepairPrivate Passenger Type Including Light & Medium Trucks - New % %Private Passenger Type Including Light & Medium Trucks - Used % %Antique/Classic Cars % %Boats - Other than Jet Skis % %Jet Skis % %Busses % %Contractors Equipment % %Farm Equipment %

4 %Emergency or Public Livery % %Heavy Truck (over 20,0000 GVW) **additional supplement required** % %Kit Cars or Other Auto Manufacturing % %Motorcycles, ATVs, Scooters, Snowmobiles **additional supplement required** % %Mobile Homes % %Recreational Vehicles and Campers **additional supplement required** % %Semi Trailers **additional supplement required** % %Trailers - Other than Semi Trailers % % TOTAL 100%DEALER OPERATIONSC osigned Autos Held for Sale %Owned Auto Held for Sale %Auto Auction %Wholesale Autos %Other: %Number of Dealer Tags.

5 NON-DEALER OPERATIONSA larm, Stereo or Navigational System %Auto Maintenance or Repair Incl. Bed liner %Auto Painting with UL approved spray booth %Auto Painting without UL approved spray booth %Auto Parts Sales Receipts: %Body Shop % %Car Wash - Full Service %Convenience Store Receipts: %Detailing %Drive away Contractor or Wrecker Service %Frame or Unibody Straightening %Gasoline Station - Full Service %Impound Yards %Mobile Auto Repair %Oil/Lube Service %Parking Lots & Garages %Tire Dealers - New %Tire Dealers - Used.

6 Retreads or Split Rims %Trailer Hitch Installation or Repair %Upholstery %Valet Parking **additional supplement required** %Van Conversion %Window Tinting %Windshield Installation/Repair %Other %VEHICLE STORAGE & VALUESO wned AutosHow are vehicles stored?Standard Lot* BuildingNon-Standard Lot* Unfenced LotMaximum value any one Auto?Maximum value of all Autos?Average number of Autos?Non-Owned AutosHow are vehicles stored?

7 Standard Lot* BuildingNon-Standard Lot* Unfenced LotMaximum value any one Auto?Maximum value of all Autos?Average number of Autos?Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet in height; or bounded on one or more sides by the wall or walls of a building, with no unprotected opening, and with the exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with openings securely locked when unattended.

8 Non-Standard Lot: Any other type of protection or unprotected of Pickup & Delivery:None 0-300 Miles 301-500 Miles 501-1000 Miles+1000 MilesEMPLOYEE AND NON-EMPLOYEE INFORMATIONYOU MUST COMPLETE THE FOLLOWING INFORMATION FOR ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS*Refer to the guides below for status, hours worked, and auto use .Name and Driver s License # & StateDate of BirthViolations & Accidents Prior Three yearsStatusHoursWorkedAuto UseSTATUS: 3. Salesperson 9. Spouse of any other person furnished an auto4.

9 Lot Person 10. Children of any other person furnished an auto5. Mechanic 11. Occasional or Contract Driver6. Clerical 12. OtherHOURS WORKED: F = Full Time (Over 20 hours per week) P = Part Time (20 or less hours per week) N =Non-Employee AUTO USE:A = Furnished a covered auto for personal useB = Uses a covered auto strictly for business useC = Does not drive a covered autoADDITIONAL INFORMATIONGARAGE LIABILITY: Limit of Liability DeductibleAuto Each AccidentOther Than Auto Each AccidentOther Than Auto Aggregate LimitBIPDPERSONAL INJURY PROTECTION OR NO-FAULT COVERAGE.

10 Per StatuteMEDICAL PAYMENTS:AutoGarage OperationsUNINSURED MOTORISTS COVERAGE:UNDER INSURED MOTORISTS COVERAGE:Each AccidentEach AccidentGARAGE KEEPERS:LegalDirect ExcessDirect PrimaryComprehensiveLimit of Coverage Limit Per Location Limit Per Auto Deductible Other Than Collision Collision In-Tow Coverage Limit Per Tow Truck # of Tow TrucksDEALERS OPEN LOT:ComprehensiveAdditional InsuredWaiver of SubrogationNameAddressInsurable InterestBroadened Coverage (includes Personal Injury & $50,000 Fire Legal) Hired AutoFire Legal LiabilityLimit Personal Injury LiabilityLimit of Coverage Limit Per Location Limit Per Auto Deductible Other Than Collision Collision ADDITIONAL COVERAGES.