Name of Car Wash   Contact Person   Email Address   Telephone Number   Fax Number   Number of Locations   Location Address complete 1 form for each location   City   State   Zip   Number of Years in Business   Current Ins. Policy Expiration Date   Value of Building   Value of Contents   Value of Equipment   Type of Construction Wood Masonry   Roof Support Wood Steel   Age of Building   Number of Stories   Square Footage   Alarm Yes No   Primary Type of Wash Exterior Full Serve In Bay Automatic Self Serve   Annual Location Receipts   Number of Full Time Employees   Number of Part Time Employees   Umbrella Limit $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,00   Drive Non-Owned Autos ? Yes No   Do you Hire Autos ? Yes No