| Name |
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| Contact Information |
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| Address |
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| Legal Name of Company |
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| Date you need coverage to begin |
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| Doing Business As |
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| Mailing Address |
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| City |
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| State |
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| Zip Code |
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| Legal Structure |
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| Years in Business |
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| Owner’s name |
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| Phone |
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| Email |
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| Fax |
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| Federal Tax ID# |
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| Current insurance carrier name |
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| Has the insurance coverage ever been cancelled or not renewed? (Y or N) |
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| Any claims paid in the last three years (Y or N, If yes - please list any losses in the last three years) |
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| Street Address, City, State, Zip Code |
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| Please provide your total inventory value dollar amount? |
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| Maximum - New Value |
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| Maximum - Used Value |
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| Average - New |
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| Average - Used |
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| Number of Demos/Furnished Autos |
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| How many vehicles are parked in/under each of the following structures? |
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| Multi Story Parking Structure |
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| Single Story Building |
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| Hail Net / Awning Structure |
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| What is TOTAL number of vehicles the dealer could protect at this location from hail damage if you had time to move them? Consider OFF site buildings if available |
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| How Long would it take to move this number of vehicle? |
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| What is the maximum value of any one vehicle? |
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| Auto Inventory Key Controls (safe, locked office, lockbox, key machine, keys taken home at night) |
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| Are test drives accompanied? (Y or N) |
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| Is insurance verified for test drivers? (Y or N) |
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| Do you provide loaner vehicles? (Y or N) |
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| - If yes do you use a written loaner agreement? (Y or N) |
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| Are buyers guides posted in all vehicles held for sale? (Y or N) |
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| Are written inspection records kept? (Y or N) |
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| Please let us know of any other insurance or liability concerns you would like for us to address |
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| Has any part of your vehicle storage or parking areas ever flooded in the last ten years? (Y or N) |
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| Are any of your vehicle storage areas or parking areas located in a 100-year flood zone?( Y or N) |
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| Has dealer’s location(s) flooded in the past 10 years? ( Y or N ) |
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| Is on premises security service used? ( Y or N ) |
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| Is lot fully enclosed after business hours? ( Y or N ) |
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| Are gates locked when business is closed? ( Y or N ) |
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| Describe Method of Key Storage & Key Protection (Example: Key Machine – Make & Model) |
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| How are keys returned to cabinet? Who is responsible? |
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| Are window Lock Boxes used? ( Y or N ) |
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| Number of people who are allowed to drive company owned vehicle for personal use. |
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| Does dealer insure any vehicles through Floor Plan Insurance Program? ( Y or N ) |
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| Does Dealer own a Body Shop? ( Y or N ) |
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| Lienholders, Address, City, State, ZIP, Lienholder Group |
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| Enter the location #'s to which this lienholder applies |
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