NATSN Insurance Program
Business Name:
Entity Type (LLC, Inc.):
Inc.
LLC
Partnership
Sole Proprietorship
Year business established:
FEIN#:
Mailing Address:
Insured Contact:
Phone:
Email:
Fax:
Current Insurance Carrier/Carriers:
Effective Date of Coverage:
Total Annual Premium:
How many truck stops and c-stores do you operate?
1
2
3
>3
Do you operate a casino?
No
Yes
Do you have Fuel Jobbers?
No
Yes
Sales Information
Annual Gasoline Gallons Sold:
Annual Diesel Gallons Sold:
Convenience Store Sales:
Beer/Wine Sales:
Liquor Sales:
Restaurant Sales/Cooking Sales:
Car/Truck Wash Sales:
Repair Shop Sales:
Other Sales:
Property
Location Address:
Check if same as mailing address:
# of Structures on Premise:
1
2
3
Structure 1
Full Value:
Description:
Building
Canopy
Storage Facility
Other Retail
Contents Replacement Cost:
Sq Ft:
Sq Ft of Retail (C-Store & Restaurant) Operations:
Building Construction Type:
Frame
Masonry
Sprinklered:
Yes
No
Burglar Alarm:
Yes
No
Fire Alarm:
Yes
No
Deductible Options:
$1000
$5000
$10000
Hours of Operation:
Firearm on Premises:
Yes
No
Parking Lot Acres:
# of Overnight Parking Spots:
Structure 2
Full Value:
Description:
Building
Canopy
Storage Facility
Other Retail
Contents Replacement Cost:
Sq Ft:
Sq Ft of Retail (C-Store & Restaurant) Operations:
Building Construction Type:
Frame
Masonry
Sprinklered:
Yes
No
Burglar Alarm:
Yes
No
Fire Alarm:
Yes
No
Deductible Options:
$1000
$5000
$10000
Hours of Operation:
Firearm on Premises:
Yes
No
Parking Lot Acres:
# of Overnight Parking Spots:
Structure 3
Full Value:
Description:
Building
Canopy
Storage Facility
Other Retail
Contents Replacement Cost:
Sq Ft:
Sq Ft of Retail (C-Store & Restaurant) Operations:
Building Construction Type:
Frame
Masonry
Sprinklered:
Yes
No
Burglar Alarm:
Yes
No
Fire Alarm:
Yes
No
Deductible Options:
$1000
$5000
$10000
Hours of Operation:
Firearm on Premises:
Yes
No
Parking Lot Acres:
# of Overnight Parking Spots:
Do you have equipment, other than vehicles, that leave your premise?
Yes
No
What?
Maximum Value of that Property:
Worker's Compensation
Payroll
# Employees
C-Store/Retail:
Restaurant - Fast Food:
Restaurant - Traditional:
Auto Service Repair:
Clerical:
Would you like a deductible option?
Yes
No
Autos/Trucks
How Many?
1
2
3
Auto 1
Year:
Make:
Model:
Vin#:
Cost New:
Comprehensive Physical Damage?
Yes
No
Collision Physical Damage?
Yes
No
Radius:
0-50 miles
50-150 miles
150+ miles
Driver's Info:
Name:
License #:
License State:
Birthday:
Auto 2
Year:
Make:
Model:
Vin#:
Cost New:
Comprehensive Physical Damage?
Yes
No
Collision Physical Damage?
Yes
No
Radius:
0-50 miles
50-150 miles
150+ miles
Driver's Info:
Name:
License #:
License State:
Birthday:
Auto 3
Year:
Make:
Model:
Vin#:
Cost New:
Comprehensive Physical Damage?
Yes
No
Collision Physical Damage?
Yes
No
Radius:
0-50 miles
50-150 miles
150+ miles
Driver's Info:
Name:
License #:
License State:
Birthday:
Umbrella
Requested Limit:
$1mil
$2mil
$3mil
$4mil
$5mil
$10mil
Other
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Truck Stop Operations
Do you have video game arcades?
Yes
No
ATM on premise?
Yes
No
Check cashing, faxing, and/or money wiring?
Yes
No
Annual sales:
How often is cash dropped off-site?
Is there a trucker's lounge?
Yes
No
Are there sleeping quarters
or a motel attached to the truck stop?
Yes
No
Repair facility for large trucks?
Yes
No
Is it owned and operated by you?
Yes
No
Shower facilities provided?
Yes
No
How many?
Is there a restaurant?
Yes
No
What type?
What type of cooking?
Open Flame
Fryer
Deli
Pizza
Last date of kitchen
extinguishing system maintenance:
Is there a formal safety program?
Yes
No
Is there a formal cleaning program?
Yes
No
Do you refill LP Gas/Propane Tanks?
Yes
No
Do you operate tow trucks?
Yes
No
How many and what is their radius?
Pollution
# of Underground Storage Tanks (USTs):
# of Above Ground Storage Tanks (ASTs):
Are you registered and filed with the state?
Yes
No
What state?
Do you require additional Pollution Liability
Coverage other than the State Remediation Fund?
Yes
No
I don't know
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