Gas Station Questionnaire

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Legal Entity Name*

Doing Business As (if applicable)

Business Physical Address*

Street Address Address Line 2 City State ZIP Code

*If your state is not shown, then JMG may not have a market for this state.

Mailing Address

Same as previous

Federal Tax ID Number

Year Business Started

Please enter a number from 1000 to 9999.

Any Claims In The Last Five Years*

Full-Time Employee Count

Part-Time Employee Count

Estimated Annual Payroll

Total Number of Pumps

Number of Nozzles

Any Auto Repair Operations*

Annual Sales*

Any Dealer/Repair Plates*

List Plate Numbers*

Any Used Car Sales*

How Many a Month*

Average Value of Cars:*

Any Convenience Store Operations*

Annual Sales:*

Any Alcohol Sales*

Any Towing Operations*

How Many Trucks*

Any Canopy over the Pumps*

Estimated Annual Gallons Sold

Auto Quote Needed?

Contact Person Name*

Phone Number*

Email Address*

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Agent

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