State: Zip:

Yes No Do you have more than one location?

State: Zip:

Detailed description of business activities (specifically, and by location):

Please list the business owners and decision makers involved in the business:

Phone Number: (702) 685-2074

Headquarters: 9300 Sun City Blvd #105

Las Vegas, Nevada 89134, USA

Email: quotes@westernskiesmga.com

Physical address of business if different:

City:

Yes

Annual Payroll:

Name Role Contact Number E-mail Address

Annual Gross Receipts:

Clear all fields

Western Skies MGA, LLC 1 of 9 Ed. 7/2020 v3

Proposed Effective Date:

Producer Name:

Producer Email:

Producers Phone #:

Name Insured:

DBA:

Mailing Address:

City:

Email:

Business Type:

Fax:Business Phone:

FEIN:

Is this a new business? No

Years in business:Date business started:

DOT #

Yes No

Yes No

Provide names for all insurance companies that have provided applicant insurance for the last fouryears:

Company Name

Coverage

Limits

Annual Premium

Does the insured have any contract requirements? (If yes, please attach a copy)

What is the target premium?:

Is the current insurance carrier offering a renewal quote?

If yes, please provide the premium offered:

If no, explain:

Current coverage/Company information: 

Policy Term Paid Claims Reserved Claims Total Incurred Claims

Western Skies MGA, LLC 2 of 9 Ed. 7/2020 v3

Insurance History

From: To:

Company Name

Expiration Date

Annual Premium

Limits

Coverage Type

Attach/ Upload a four-year loss/claims history

Are you aware of any incident, event, or occurrence, loss that might reasonably be expected to lead to a

claim, lawsuit, notice of loss, or loss that was not reported to your prior carrier?

If yes, please explain:

Camera equipment coverage?

$1,000,000/$1,000,000

$1,000,000/$2,000,000

$1,000,000/$3,000,000

Yes No

Yes No

$300,000

$500,000

$1,000,000

$25,000/$75,000

General Liability Please Select:

Limit of Garage LiabilityPlease Select:

CSL Accident/ Aggregate Accident/ Aggregate

Desired Insurance

Auto Liability Please select:

Is Garage Keeper's coverage needed? Yes No

(Physical damage for customer’s vehicle in the named insured’s care, custody, and control): If yes, please

select:

Average number of vehicles at any one time

Maximum number of vehicles at any one time

Average value per vehicle

Maximum value per vehicle

Average value in storage at any one time

Maximum value in storage at any one time

Location 1

Location 2

Location 3

*Please complete the below table for needed GKLL/GKDP

Legal liability basis (GKLL)

Direct primary basis (GKDP)

Western Skies MGA, LLC 3 of 9 Ed. 7/2020 v3

$750,000$50,000/$100,000

$100,000/$300,000

Other

Yes No

Wrongful Repo:

Is Wrongful Repo coverage needed?

If yes, please select: $100,000

$500,000

$300,000

$1,000,000

Comprehensive Deductible:

$1,000

$2,500

$5,000

$10,000

Collision Deductible:

$1,000

$2,500

$5,000

$10,000

Physical Damage

$25,000

$50,000

$100,000

Other

In Tow (On-Hook):

Cargo

Other

Western Skies MGA, LLC 4 of 9 Ed. 7/2020 v3

Average Value $

Maximum Value $

Average Value $

Other:

Maximum Value $

$25,000

$50,000

$100,000

Estimated bycompany employees

%

%

%

Business Activities

Operational Revenue Percentage:

Towing

Service Garage – Body Shop

Service Garage – Auto Repair

Salvage Yard/Auto Dismantling

Auto Hauling

%

*Repossession Voluntary

*Repossession Involuntary

*Sale/Disposal of Repossessed Autos

*Other

Drive-Away Physical Damage to Vehicles Driven-Physical Damage

Limits: Over the road Physical Damage

$25,000

$50,000

$100,000

Total number of repossessions or tows - must provide a number (percentages will not be accepted)

By Exposure: Drive-Away Tow-Away (Consent/Non-Consent) Repo Tow-Away

Estimated by company employees: Estimated by independent contractors:

Total for the next 12 months:

%

%

%

%

Employee Only, named operators coverage only

Annual Gross Revenue by Operations

Annual Gross Income for Recoveries

Annual Gross Income for Towing

Physical Repair (Auto Body) of Vehicles – Gross Income

Mechanical Repair and Service to Vehicles (Tune-Up, Radiator, Air-Conditioning, Lube & Oil, Muffler, Brakes, Engine Rebuilding) – Gross Income

Storage of Vehicles – Gross Income

Used Car Sales – Gross Sales

Leased Auto Sales

Tire Sales and Services – Gross Sales

Other:

Western Skies MGA, LLC 5 of 9 Ed. 7/2020 v3

%

Type of Contracts Percentage Breakdown: Type of Vehicles Percentage Breakdown:

Motor Club

Police Calls

Dealers

Auctions

Private Calls

Banks

How many of each do you have issued to your company:

Transportation plates:

How are they used?

Repossessed plates:

How are they used?

Autos Construction Equipment

ATV's

1. Are personal effects and personal property of others recovered, and a complete and accurate

inventory made of all items?

2. How are personal property and effects returned to their owners?

3. What is done with deadly weapons, dangerous drugs, or prescription drugs found in the personal

effects and property that are removed for inventory?

4. Do you request certification of liability forms from all sub-contractors or independent contractors,

where your firm is listed as an additional named insured?

5. Do you provide or perform services as a sub-contractor to other tow truck operators, recovery

agencies, or other business operations?

If yes, please explain:

%%

%%%%

% Private Passenger Type Vehicle

% Trucks, 10K – 15K lbs

% Trucks,Over 20K lbs- Tractors Over 26K% Watercraft (Boats, Jet Skis,Etc.)

% Motorhomes

% Other

What kinds of property do you repossess? (check all that apply):

Tractor/Trailer

Boats

Heavy equipment

Motorcycles Other

Yes No

Yes No

Yes No

Western Skies MGA, LLC 6 of 9 Ed. 7/2020 v3

% Other

101-200 miles: %

Yes No Do you have a written equipment maintenance program?

Are loaded trucks ever left unattended?

Please answer the following questions related to recover tow truck operations and service vehicles

connected with your business:

Yes No

Radius of operations (show percentage of total miles driven):

0-50 mi les: % 51 -100miles: %

Provide a copy of your training program and/or safety program:

Yes No

Yes No

Yes No

Do you always use safety chains?

Are you equipped with wheel lifts?

Do you lift or haul other than vehicles?

If yes, please explain:

Where are the customer vehicle keys kept?

What is the company policy regarding handling of keys?

What are the circumstances for relinquishing vehicles?

Do you provide Workers' Compensation for all employees,

including drivers?

Do you transport any caustic, radioactive, or flammable cargo?

Do you operate under anyone else's permit or authority?

If yes, explain:

Yes No

Yes No

Yes No

Western Skies MGA, LLC 7 of 9 Ed. 7/2020 v3

201-500 miles: %

DO NOT SIGN UNTIL YOU HAVE READ THE CONTENTS OF THIS APPLICATION AND THE APPLICABLE FRAUD WARNING(S).

I have reviewed the contents of this application and with my signature, I declare to the best of my

knowledge that all statements herein are true and no material facts have been suppressed or misstated. I

am also aware that my operation may be inspected by the Insurance Company.

SIGNATURES

APPLICANT/NAMED INSURED

APPLICANT/NAMED INSURED SIGNATURE DATE

Yes No

Agent/Broker:

Are you personally familiar with this Applicant's operations?

Did your office control this risk in the past year? No

AGENT’S OR BROKER’S NAME AND ADDRESS TELEPHONE NUMBER LICENSE NO.

AGENT’S OR BROKER’S SIGNATURE DATE

Yes

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 misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to a civil penalty or fine.

Western Skies MGA, LLC 8 of 9 Ed. 7/2020 v3

FILINGS

DATE:

1. Insured's Name:

(Must read exactly as the Insured is registered with the State Commission and ICC application)

2. Insured's Address:

(Must read exactly as the Insured is registered with the State Commission and ICC application)

3. Please indicate filings required:

CA DMV 65 MCP

Colorado 10, 12, 14

Form E: Indicate the states needed:

Form H: Indicate the states needed:

ICC BIPD (BMC 91X)

ICC Cargo (BMC 34)

MCS 90

Texas Form T

Other:

4. Please Supply Filing Numbers:

ICC MC#

US DOT#

STATE ID#

Texas Certificate# (For Form E & H).

Texas VSF # (For Form T).

Colorado Permit #

California Motor Carrier#

Other filings number:

Western Skies MGA, LLC 9 of 9 Ed. 7/2020 v3