CAR WASH/GAS BAR QUESTIONAIRE
Erb and Erb Insurance Brokers Ltd.
 Company Name:              
Legal Name of Company:
Company Address:      City:      Province    Postal Code
Contact Person: Email Address:    Phone #: Fax #:
Present Insurance Company: Policy #: Expiry Date:

PROPERTY OF EVERY DESCRIPTION  (Fill in ALL Blanks. If NONE, State NONE.)

Building #1: $  Tenant Improvements: $  Hoists: #$  Canopy (Height in feet)$  Awnings:#$

Building #2: $  Office Equipment:       $   Signs:$   Stock: $

Building #3:$ Underground Tanks:  #$ Aboveground Tanks:  #$ 

Max Gas Value:$  Max Propane Value:$

Gas Pumps:  #$  Propane Tanks:  #$  Propane: $  Inside Car Wash Equipment: $

Outside Car Wash Equipment  Vacuums:  #$  Vending Machines:  #$  Equipment (Fences, Lights, etc.) $

Other operations not already included:      $

Sales Per Year  (If NONE, State NONE.)

Gas Sales: $  Drive Through Car Wash Sales: $  Coin Op Car Wash Sales: $  Convenience Sales: $

Propane Sales: $  Repair Shop Sales: $  Other Sales Not Already Included: $

Desribe Other Sales (e.g. Lube Shop, Restaurant):   If Restaurant, Advise of Liquor Receipts $

Underwriting Information  (Please Check the Right Description)

Construction
Building #1: Roof Construction: Concrete Steel Deck Wood Joist  
                     Wall Construction: Concrete Steel Brick/Frame
                     Age of Building Sq. Ft.
Building #2: Roof Construction: Concrete Steel Deck Wood Joist  
                     Wall Construction: Concrete Steel Brick/Frame
                     Age of Building Sq. Ft.
Building #3: Roof Construction: Concrete Steel Deck Wood Joist  
                     Wall Construction: Concrete Steel Brick/Frame
                     Age of Building Sq. Ft.

Are you within 500ft of a fire hydrant? Yes No   Do you have an alarm system? Yes No   Maximum cash on site at any time? $

Garage Auto Policy

Employee Breakdown   Car Wash  Owners Valet Service Full Time Line Workers Part Time Line Workers Detail Shop Workers
                        Convenience Store Cashiers            Others
    Gasoline & Service Station Attendants  Gas Attendants Kiosk Cashiers Mechanics Others
                # of Dealer Plates       Do you clean boats? Yes No    If yes, Maximum value of any one boat $

Claims Experience

# of Years in Business       Any Claims in The Past 6 Years? Yes No      If so, list below

 Date of Loss  Description of Loss  $ Amount Paid Out