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Back to Express Requests

Garage Express Request

*Complete and submit the form below for an Express Premium Indication from OGA’s Small Business Unit

Fax: 405.840.9388 | 800.771.8116
Phone: 405.840.9393 | 800.299.1951

Agency Information
Applicant Information
Prior Carrier & Loss Information

Within a 3 year history

Operations
Type & Percentage of Vehicles Applicant Sells or Services
%
%
%
%
%
%

Please list each: Name | Date of Birth-Age | Furnished Auto (Yes or No) | Job Description/Relationship | Full-Time or Part-Time

E.G.: John Smith | 01/01/1980-31 | Yes | Spouse | Part-Time

*Subject to MVR

Please list each: Name | Date of Birth-Age | Job Description/Relationship | Full-Time or Part-Time

E.G.: John Smith | 01/01/1980-31 | Spouse | Part-Time

Miles
Garage Liability
$ Each Accident
$ Aggregate
Garage Keepers
$ Per Location
$
$
$
Dealers Physical Damage
$ Per Location
$
$
Medical Payments
$
Uninsured Motorist
$

Please list each as: Year | Make | Model | Stated Amount | MGVW | Use | Radius of Operation

Please Note

In order to Bind Coverage, we will need a fully completed and signed Garage Application. Premium indication is subject to change upon receipt of company specific applications and any required supplemental.

If needed, please include any comments or additional information here.

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Wholesale & Specialty Insurance Association Independent Insurance Agents of Oklahoma Oklahoma Surplus Lines Association USA Alliance