Renter’s State Minimum, Renter’s Additional & Renter’s Personal Protection

Application for Sales Agent Approval

PLEASE FILL OUT THE FOLLOWING INFORMATION.

COMPLETE APPLICATIONS WILL BE APPRECIATED AND HANDLED PROMPTLY.

Company *

DBA

Street Address *

Address Line 2

City *

State *

Zip Code *

EIN # *

Email Address *

Owners Name (First/Last) *

Additional Owners (First/Last) *

Phone Number *

*

	Current Year	Last Year	Prior Year
Average Fleet Size	Current Year	Last Year	Prior Year

*

	15 Pass	RV’s	Cars/SUV
Fleet make-up	15 Pass	RV’s	Cars/SUV

What is the average age of your fleet? *

What is your average annual fleet utilization? *

Do have any accounts that offer coverage other than Statutory limits? *

Yes

No

Who is your primary insurance carrier? *

What are the limits of liability? *

What are your monthly rates? *

What is the renewal date of your primary automobile insurance policy? * +

Please supply loss runs for the past three years. *

Who is your Physical Damage insurance carrier? *

What is the deductible? *

What are your monthly rates? *

Have you ever submitted a Supplemental Liability Claim? *

Yes

No

If so, please provide a description below.

Do you sell a Liability product? *

Yes

No

Who is the Liability insurance carrier?

What is the daily rate you charge for your liability insurance?

Addresses of additional rental locations if applicable:

What is your experience in the daily rental industry? *

Important Information

Coverage is not provided for transportation network vehicles. Vehicles for hire.

This submission is a direct transaction with the insurance company.

Coverage provided is on an Excess and Surplus Lines basis.

Coverage is not bound until underwritten and confirmed in writing by the insurance company.

Coverage may apply to 15 passenger vehicles if approved by underwriter, at a higher premium.

If coverage is bound by the insurance company this application will be

included as a part of the policy issuance.

The information submitted is, to the best of my knowledge, accurate and correct.

Please sign with your mouse or finger *

clear

Please Print the Name of Applicant *

Date of Signature * +