Gas Station Insurance Intake Form

1

Business Identity

Legal Business Name (LLC / Corp / DBA)

DBA / Trade Name (if different)

Entity Type

# of LLC Members / Managers

FEIN / Tax ID or SSN

Date Business Started

Years in Business

Under Same Management?

YesNo

2

Location & Contact

Mailing Address

City

State

ZIP

Is the location / risk address the same as mailing?

YesNo

Location / Risk Address

City

State

ZIP

County

Within City Limits?

Owner / Primary Contact

Owner / Contact Name

Owner Phone

Owner Email

Business Phone

Website

3

Operations

This location is open 24 hours / 7 days a week

Hours of Operation

Days Open

Full-Time Employees

Part-Time Employees

Min. Cashiers on Duty at Any Time

Total Building Sq. Footage

Occupied Area (sq ft)

Open to Public Area (sq ft)

Any Area Leased to Others?

YesNo

Description of Operations

4

Revenue & Sales

5

Liquor / Alcohol

6

LPG / Propane

LPG Tank Filling on Premises?

YesNo

LPG Tank Swap / Exchange on Premises?

YesNo

Filled By

LPG Annual Sales ($)

Are there protective barriers around the tanks?

YesNo

7

Food & Cooking

8

Car Wash

Is There a Car Wash on Premises?

YesNo

Describe the car wash (type, number of bays, etc.)

9

Auto Repair

Any Auto Repair Services on Premises?

YesNo

Describe auto repair services offered

10

Security & Safety

11

Building & Property

Construction Type

Year Built

Number of Stories

Roof Type

Burglar Alarm Type

Year of Last Updates

Wiring

Plumbing

Roofing

Heating

Distance to Fire Hydrant (ft)

Distance to Fire Station (miles)

Habitational / Apartment Units on Premises?

YesNo

Number of Units

Drive-Up Window?

YesNo

12

Property Values

Provide estimated replacement cost values. Leave blank if not applicable.

Gasoline Pumps Value

Canopy Value

Building Value

Business Personal Property (BPP)

Property Deductible

13

Current / Prior Insurance

Current Policy

Current Carrier

Policy Number

GL Premium ($)

Property Premium ($)

Effective Date

Expiration Date

Prior Year 1

Carrier

Policy Number

GL Premium ($)

Property Premium ($)

Effective Date

Expiration Date

Prior Year 2

Carrier

Policy Number

GL Premium ($)

Property Premium ($)

Effective Date

Expiration Date

Has any policy been declined, cancelled, or non-renewed in the past 3 years?

YesNo

Reason

14

Loss History

Any Losses or Claims in the Past 5 Years?

YesNo

15

Additional Questions

16

Mortgagee / Additional Interest

If there is a mortgage, lender, or loss payee on the building, provide their information here.

Interest Type

Loan / Reference #

Name of Mortgagee / Lender

Address of Mortgagee / Lender

17

Desired Coverage

Desired Policy Effective Date

Lines of Coverage Needed (check all that apply)

GL Each Occurrence Limit

GL General Aggregate Limit

Property Deductible

Umbrella / Excess Limit Desired

Additional Notes / Remarks

18

Photos

Attach photos of the interior and exterior of the location. Accepted formats: JPG, PNG, HEIC, WEBP.

Drag & drop photos here

or click to browse files

By submitting this form, you confirm that the information provided is accurate and complete to the best of your knowledge. Incomplete or inaccurate information may affect the ability to obtain coverage.