Auto Parts or Repair Insurance
   

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acknowledgement from a Powers & Company Representative.
All quotes subject to final underwriter/carrier approval.

Items marked with * are required to process this form correctly.

*Business Name:
 
*Business Address:
 
*City:
 
*State:
CA
 
*Zip:
 
*Number of Owners
 
*Owner/Contact Name:
 
  Mobile Phone:
   
*Business Phone:
 
  Business Fax:
 
*Business Email:
 
*Description of Operations:
 
*Maximum Value of Customer
  Vehicles on Premises:
$
 
*Estimated Gross Annual Receipts:
$
 
*Number of Mechanics:
 
 
*Liability Limit:

$500,000/$1,000,000
$1,000,000/$2,000,000
 
 
*Claims in the Last Three Years?:
Yes    No
 
*Years Continuous Liability Coverage:
1     2     3
 
  Current Insurance Carrier:
 
  Policy Expiration Date:
 
*Number of Years in Business:
 
*How Did You Find Us?

Flyer in the mail   
Faxed flyer
Online search
Referral
Other (If checked, please specify:

 
 
 
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