Auto Repair Shop Request Form

Thank you for your interest in the Liberty Mutual Insurance Total Liberty Care (TLC) Program.

Please submit your application by answering the questions below. Completing the request below will ensure your interest is received by Liberty Mutual Insurance.

You will be contacted if there is a need for a TLC facility in your area and if your facility meets our requirements.

* Shop Name:
* Shop TIN:
* Address Line 1:
Address Line 2:
Address Line 3:
* ZIP Code:
* City:
* State:
County:
* Primary Contact:
* Primary Phone:	(ex. 111-111-1111)
* Email:
Website Address:
*Does your facility use PerformanceGateway / PerformanceClaims?	Yes No
* What is the shop square footage?
*Do you use an automated facility management system or a body shop management system? (check all that apply)	ABF Systems ABW Tracker Audatex New Era iAutoFocus Auto Claims Solutions RTI CCC One CCT's CC3 CRISMA Mitchell ABS Enterprise NEXSYIS NEXconnex ProfitNet Rome Technologies CompleteShop Stellix Summit Other N/A
*What Estimating system do you use? (check all that apply)	ADP Penpro ADP Shoplink Audatex CCC Autoverse CCC Comp-Est CCC One CCC Pathways Crash-writeR Mitchell RepairMate Mitchell TruckEst Mitchell Ultramate WebEst Other N/A
*Do you use a computerized 3-Dimensional frame measuring system? (check all that apply)	Car-O-Liner's Car-O-Tronic Vision and Classic Cellete and Car Bench with Photos of pre/post pull Chassis Liner CLC Pro Chief's Genersis 2, Velcoity or Vector w/ optional upper body Gold Medallion Collision Repair System Grabber G-Tronics (rebranded Chief Vector) Grabber G-Tronics (rebranded Velocity) Kansas Jack Brewco The Wolf Matrix Electronic Measuring System Shark (Blackhawk) Tru-Point Sonic 360 The Touch Computerized measuring system by CEG VERTEX measuring from Chief Other N/A
*Does your repair facility CURRENTLY have I-CAR “GOLD” status?	Yes No
* I-CAR Gold Expiration Date:	(ex. mm/dd/yyyy)
*Are there seating and restrooms available for your customers?	Yes No
* General Liability Limits:
*Does the Commercial General Liability policy include Products / Completed Operations Coverage?	Yes No
* How long is your body repair warranty in years?	(please enter ‘0’ if none; enter ‘99’ if unlimited)
* How long is your paint repair warranty in years?	(please enter ‘0’ if none; enter ‘99’ if unlimited)
* What is the monthly average number of cars repaired at your body shop?