/ AUTO DEALER APPLICATION

Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.

An Additional Information section is provided at the end of this document for any information that exceeds the space provided or attach any applicable document.

GENERAL INFORMATION

Proposed First Named Insured And Other Named Insureds: / Today's Date: (mm/dd/yyyy):
Mailing Address:
Telephone Number: / Web Address:
Type of Legal Entity: / Number of Years in Business:
Proposed Effective Date (mm/dd/yyyy): / Proposed Expiration Date (mm/dd/yyyy):

TYPE OF DEALERSHIP INFORMATION

1. Indicate if Auto Dealer is: Franchised Non-Franchised

Enter a percentage for those that apply:

Car / %
Truck-Tractor / %
Motorcycle / %
Recreational Vehicle / %
Snowmobile / %
Other: / %

2. Describe any secondary operations: (Mini Marts, day care, playgrounds, car wash, etc.)

3. Do employees regularly use own autos on company business? Yes No

If yes, include the number of employees and the description of use:

AUTO DEALER LOCATION INFORMATION

4. List all Auto Dealer locations:

Location No. / Address – Street, City, State, Zip Code (State your main business location first) / Type of Operations

COVERED AUTOS* COVERAGE INFORMATION

*Coverage options are based on dealer’s headquartered state requirements.

Coverage / Covered Auto Symbols / Limits / Deductibles
Liability / 21 22 23 24 27 28 29
/ $ / $
Full Covered Autos Liability Limit for Customers
Medical Payments / 21 22 23 24 27 28 29
/ $ / $
Uninsured Motorist / 22 23 24 26 27 / CSL / BI EA PER $
BI Each Accident / $
Property Damage Ded / $
Property Damage / $
Underinsured Motorist / 22 23 24 26 27 / CSL / BI EA PER $
BI EA Accident / $
Plates: / # Dealer/Transporter / # Transportation
Personal Injury Protection
Single Limit
Split Limit / 25 27 / Each Person $ / Named Insured
Named Ins & Resident Relatives
Ded $
Additional Personal Injury Protection / 25 27 / Each Person $ / Each Accident $
Named Insured / Named Ins & Resident Relatives

COVERED AUTOS STATE SPECIFIC COVERAGE INFORMATION

Arkansas
Personal Injury Protection 25 27
Medical Payments / Each Person $
Work Loss / Accidental Death $
Connecticut
Basic Reparations Benefits 25 27 / Limit $
Added Reparations Benefits 25 27 / Per Week $
District of Columbia
Personal Injury Protection 25 27 / Deductible $
Work Loss $
Medical Funeral $
IOWA
Uninsured Motorist
Stacked
Non-Stacked / 22 23 24 26
27 / CSL BI Each Person $
BI Each Accident $
Kentucky
Motorcycle PIP 25 27 / $ Applies To Motorcycles Listed*
Named Individual Broadened PIP 25 27 / $ Applies To Individuals Listed*
Uninsured Motorist
Stacked
Non-Stacked / 22 23 24 26
27 / CSL BI Each Person $
BI Each Accident $
Underinsured Motorist
Stacked
Non-Stacked / 22 23 24 26
27 / CSL BI Each Person $
BI Each Accident $

*List Motorcycles/Individuals In The Space Provided In The Additional Information Section.

Maryland
Personal Injury Protection 25 27 / $2,500 Per Person
Waiver Of PIP
Massachusetts
Compulsory Personal Injury Protection
25 27 / Per Person $ / Deductible $
Yourself Yourself & Family Members
Compulsory: Damage To Someone Else’s Property 21 22 23 24 27 28 29 / Each Accident $
Optional Medical Benefits
21 22 23 24 27 28 29 / Each Person $
Optional Medical Payments
21 22 23 24 27 28 29 / Each Person $
Compulsory Uninsured Motorist
21 22 23 24 26 27 / CSL BI Each Person $
BI Each Accident $
Property Damage $
Underinsured Motorist
21 22 23 24 26 27 / CSL BI Each Person $
BI Each Accident $
Optional Bodily Injury To Others
21 22 23 24 27 28 29 / Each Person $
Each Accident $
Michigan
Limited Property 25 27 / Each Accident $1,000
Property Protection 25 27 / Each Accident $1,000,000
Minnesota
Personal Injury Protection 25 27 / $100 Med Exp Ded / $200 Work Loss Ded
$100/$200 Med Exp Ded/ Work Loss Ded / No Deductible
Work Loss Exclusion Named Ins Only, Age 65 Or Older, Or Age 60-64 & Retired & Receiving A Pension
Work Loss Exclusion Named Ins & Any Family Member, Age 65 Or Older, Or Age 60-64 & Retired & Receiving A Pension
Work Loss Exclusion Any Family Member, Age 65 Or Older, Or Age 60-64 & Retired & Receiving A Pension
Additional PIP 25 27 / Work Loss $
Additional Medical Exp $
MONTANA
Uninsured Motorist
Stacked
Non-Stacked / 22 23 24 26
27 / CSL BI Each Person $
BI Each Accident $
Uninsured Motorist
Stacked
Non-Stacked / 22 23 24 26
27 / CSL BI Each Person $
BI Each Accident $
New York
OBEL 25 27 / $
Additional PIP 25 27 / $ / Work Loss $
Other Exp $ / Death Benefit $
Work Loss Coord 25 27 / YES NO
Medical Exp Elim 25 27 / Named Ins Only
Named Insured & Relatives
Statutory Uninsured Motorist
22 23 24 26 27 / CSL BI Each Person $
BI Each Accident $
Supplementary Uninsured / Underinsured Motorist (Sum) 22 23 24 26 27
North Dakota
Additional PIP 25 27 / Work Loss / Surviv Inc Loss $
Repl Svcs / Srv Rep Loss $
Funeral Exp $
Total Addl PIP Limit $
New Jersey
Personal Injury Protection 25 27 / Health Insurance Option Yes No
Medical Exp $
Deductible $
Ext Med Exp Each Person $
Oregon
Personal Injury Protection 25 27 / $ Medical Exp Ded None $100 $250 Named Insured Named Ins & Family Members
Pennsylvania
First Party Benefits 25 27 / Med Exp $ / Funeral $
Work Loss $ / Acc Death $
Combination First Party Benefits 25 27 / Total Benefit Limit $
Funeral $
Acc Death $
Extraord Med Ben 25 27 / $
South Dakota
Supplemental Auto Coverages 25 27 / Total Disability Benefits $
Auto Death Ben $10,000 Each Person
$60 Per Person Gainfully Employed
$30 Per Person – Not Gainfully Employed
UTAH
Personal Injury Protection 25 27 / Medical Exp $ / Inc Ben $
Waive Income Benefits
Funeral Exp $ / Survivor Loss $
Additional PIP 25 27 / Medical Exp $ / Inc Ben $
Waive Income Benefits
Funeral Exp $ / Survivor Loss $

PHYSICAL DAMAGE INFORMATION

*Physical Damage
Comprehensive / 22 23 24 27 28 31
Specified Causes of Loss (describe coverage desired in the Endorsements/Remarks section) / 22 23 24 27 28 31
Collision / 22 23 24 27 28 31
Blanket Collision Limit / $ / Blanket Collision Deductible / $

*Complete Location Detail Information Section for all locations

Coverages / Types of “autos” / Interest covered
New / Used Autos, demonstrators and service vehicles / Your interest in covered “autos” you own / Your interest only in financed covered “autos” / Your interest and the interest of any creditor named as loss payee / All Interests in any “auto” not owned by you or any creditor while in your possession on consignment or sale
Comprehensive
Specified Perils
Collision

Covered Auto Symbols

(21) Any Auto
(22) All owned Autos
(23) Owned Private Pass Autos Only
(24) Owned Autos Other than Priv Pass / (25) Owned Autos Subject to No-Fault
(26) Owned Autos Subject to UM Law
(27) Specifically Described Autos
(28) Hired Autos Only / (29) Non-Owned Autos used in Garage Bus
(30) Autos Left for Service/Repair/Storage
(31) Autos On Consignment and Dealer Autos
(32) Company Use
Additional locations where you store covered "autos" / $
In Transit / $

Indicate Premium Basis: Non-reporting basis

Reporting basis: Quarterly Monthly

Endorsements / Remarks (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Auto Dealers Xtend Endorsement…………………..(CA T4 25)
Truck Dealer Extension Endorsement……………..(CA T3 63)
Fluctuating Values Endorsement……………………(CA T4 70)
Replacement And Repair……………………………...(CA T3 83)
Customer Complaint Legal Defense Coverage...... (CA T4 28)
Lemon Law Coverage…………………………………..(CA T3 58)
False Pretense Coverage………………………………(CA T4 57)
Other: (describe)

GENERAL LIABILITY COVERAGE INFORMATION

Coverages / Limits
General Liability Bodily Injury And Property Damage Liability / $ / Each Accident
Damages To Premises Rented To You / $ / Any One Premises
Personal Injury And Advertising Injury / $ / Any One Person or Organization
General Liability (Aggregate) / $
Products And Work You Performed Aggregate / $
Locations And Operations Medical Payments / $
Acts Errors Or Omissions Liability Limits / $ / Aggregate
$ / Per Claim Deductible
Acts Errors Or Omissions Coverage Extension (CA T4 26)
Acts Errors Or Omissions Limits Extension (CA T4 80)

Is waste oil, etc. disposed of by outside firm with certificates? Yes No

ADDITIONAL INTEREST/CERTIFICATE RECIPIENT

ACORD 45 Attached for additional names

Interest / Rank: / Name and Address / Reference #: / Certificate Required / Interest in Item Number
Additional Insured
Loss Payee
Lienholder
Employee as Lessor
/ Vehicle:
Scheduled Item Number:
Other
Item Description:

LOCATION DETAIL INFORMATION

PROVIDE 13 MONTH OPERATING REPORT FOR EACH LOCATION TO WHICH COVERAGE WILL APPLY AND COMPLETE THE LOCATION DETAIL INFORMATION.

DRIVER INFORMATION – INCLUDE ALL FAMILY MEMBERS AND NON-EMPLOYEES

Name, City, State, &
Zip Code / Sex / *Marital Status / DOB / Years of Experience / Year Licensed / Drivers License Number / State Licensed / Date of Hire

*or Civil Union where applicable.

Applicable in kansas only: Under kansas law, the following traffic violations are not required to be reported to insurers:

1. A speeding violation of up to six mph that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph or

2. a speeding violation of up to ten mph that occurs in an area with a maximum posted speed limit from 55 mph through 75 mph.

LEASING/RENTING OPERATIONS INFORMATION

5. Is the insured the actual lessor, i.e. holding the lease? Yes No

If yes, explain:

6. Any Renting Operations other than to customers while vehicle is in for repair? Yes No

If yes, explain:

7. Loaner Policy: (Describe controls such as minimum age, proof of insurance, etc.)

(If available, attach copy of the loaner/rental agreement)

8. Dealer or factory sponsored loaners? Yes No

If yes, explain:

9. Is Mfr responsible for liability on factory loaners? Yes No

If yes, explain:
10. Number of Dealer Loaners:

11. Any courtesy vans? Yes No

If yes, are any 15 passenger? Yes No

12. Describe any non-dealer Operations: (e.g. non-dealer operations such as vehicle conversions, truck body mfg., etc.)

13. Any repair work on RVs, Buses, Fire Trucks, etc.? Yes No

If yes, do service operations include extraordinary work such as hydraulic repairs on heavy trucks,
special equipment, etc.? Yes No

If yes, describe fully:

14. Do service operations include any installation, repair and/or service of fuel system conversions
(e.g. gasoline systems to CNG, Propane, Hydrogen, etc.)? Yes No

If yes, explain:

15. Any spot delivery? Yes No

Define as either:

a. Releasing a vehicle to a customer prior to absolute final financing approval and sale or Yes No

b. Allowing potential customers to take vehicles off site unattended for prolonged test periods

(also known as puppy dogs)? Yes No

If yes, who approves the release of vehicles for spot delivery?
16. What is the number of vehicle delivery or Dealer Exchange trips > 50 miles?

17. Do you drive-away or haul-away vehicles from factory distributing point or other dealers? Yes No

18. Do you use tow trucks? Yes No

19. Do you pick-up or deliver customer’s vehicles? Yes No

PLATE INFORMATION

20. Dealer Plate Controls:

a. Number of permanent plates (parts trucks, tow trucks, etc.)
b. Number of dealer plates used for demos, loaners, and test drives
c. Number of spare dealer plates
d. Total number of dealer plates (subject to audit):

21. List the names of whom Dealer plates are assigned to:

22. How are spare dealer plates used?
23. How are dealer plates secured to avoid theft?

DEMO EXPOSURES INFORMATION

24. How many of your sales staff have demos assigned to them?

25. List the names of whom demo vehicles are assigned to:

26. Describe your Personal use policy for demo vehicles:

27. List all family members, any non-employee drivers and any driver under the age of 25 who operate vehicles and their relationship to the insured:

Name / Relationship

28. Do you allow test drives of vehicles? Yes No

If yes, describe:

29. Do you allow test drives of motorcycles? Yes No

If yes, describe:

30. Any racing activities or race vehicle sponsorship? Yes No

If yes, describe:

31. Any towing or roadside assistance provided by the insured? (If subbed out, answer No) Yes No

If yes, describe:

32. Any trucks capable of towing multiple autos? Yes No

33. Any unusual items taken in for trade? Yes No

If yes, describe items:

34. Do you have parts delivery operation? Yes No

If yes, indicate (regularly scheduled) or (not regularly scheduled) and describe parts delivery.

35. What is the radius of parts delivery? Miles:

36. Does the dealer have a body shop? Yes No

If yes, describe fire protection:

37. Do you perform spray painting or welding? Yes No

38. Are all flammables properly protected? Yes No

***Complete Full Property ACORD App***

INSURANCE AGENT'S E&O INFORMATION

39. Other than credit life, Accident & Health etc., do you sell P&C insurance? …………………… Yes No

If yes, describe:

40. Are any companies with A.M. Best’s rating of lower than A- represented? …………………… Yes No

41. Any E&O losses in past 5 years? …………………… Yes No

If yes, describe:

TITLE AND STATUTORY E&O (If Requested)

42. Describe process for Title Searches:

43. Is there a documented procedure in place for compliance with laws relating to Title, Odometer,
Prior Damage, Used Vehicle Sales, Parts Sales, Lending, Leasing? Yes No

44. Has training been provided to sales and finance employees in compliance with statutes? Yes No

45. Do you keep detailed records of customers’ prior damage and product complaints? Yes No