Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax

Transcription

1 Salt Lake City Area Office 8722 S. Harrisn St. Sandy, UT P.O. Bx 4439 Sandy, UT Fax Chicag Office 303 W. Madisn Street Suite 2075 Chicag, IL Fax USED CAR DEALERSHIP General Infrmatin Prpsed Effective Date: Applicant s Name: Applicant s Mailing Address: City: State: Zip: Cunty: Business Telephne Number: ( ) Fax: ( ) Physical Lcatin f Business (if different): Ppulatin within 50 miles: Other Lcatins Used: Physical Address: City: State: Zip: Physical Address: City: State: Zip: Please list any ther names the business is r has been knwn by: Cntact Persn: Prducer N.: Prducer s Name: Prducer s Detailed descriptin f business activities (specifically, and by lcatin): Is this a new business? Yes N If n, hw many years have yu been in business? Applicant is: Individual Crpratin Partnership Jint Venture Other (please describe): Annual Payrll: $ Ttal Number f Emplyees: Full-Time: Part-Time: Des yur cmpany have within its staff f emplyees, a psitin whse jb descriptin deals with prduct liability, lss cntrl, safety inspectins, engineering, cnsulting, r ther prfessinal cnsultatin advisry services? Yes N If yes, please tell us: Emplyee Name: Business Telephne N.: ( ) Fax: ( ) Years with Cmpany: Emplyee s Respnsibilities: UDA-A DEC2012 Page 1 f 7

2 1. Insurance Histry Wh is yur current insurance carrier (r yur last if n current prvider)? Prvide name(s) fr all insurance cmpanies that have prvided Applicant insurance fr the last three years: Cmpany Name Expiratin Date Cverage: Cverage: Cverage: Annual Premium $ $ $ Has the Applicant r any predecessr r related persn r entity ever had a claim? Attach a five year lss/claims histry, including details. (REQUIRED) Yes N Have yu had any incident, event, ccurrence, lss, r Wrngful Act which might give rise t a Claim cvered by this Plicy, prir t the inceptin f this Plicy? Yes N If yes, please explain: Has the Applicant, r anyne n the Applicant s behalf, attempted t place this risk in standard markets? If the standard markets are declining placement, please explain why: Yes N Cverage Requested (Please check): Cmmercial Liability Business Aut Liability business use f wned auts Physical Damage t wned vehicles, used fr business nly. Garage Keeper s Legal Liability (GKLL) Dealer s Open Lt legal liability fr vehicles n sale Garage Liability Limits Per Act/Aggregate $50,000/$100,000 $25,000/$50,000/$100,000 $150,000/$300,000 $75,000/$150,000/$300,000 $250,000/$1,000,000 $100,000/$250,000/$1,000,000 $500,000/$1,000,000 $250,000/$500,000/$1,000,000 Other: Other: Self-Insured Retentin (SIR): $1,000 (Minimum) $1,500 $2,500 $5,000 $10,000 GKLL - Garage Keepers Legal Liability Limits Specified Causes f Lss fire, theft, explsin, mischief and vandalism. A Deductible will apply fr each cvered aut. Cllisin: a deductible will apply fr each cvered aut. UDA-A DEC2012 Page 2 f 7

3 Lc. #1 $ Lc. #2 $ Lc. #3 $ Dealers Open Lt Cverage Limits LIMIT AT EACH LOCATION Specified Causes f Lss fire, theft, explsin, mischief and vandalism. A Deductible will apply fr each cvered aut. Cllisin: a deductible will apply fr each cvered aut. LIMIT AT EACH LOCATION Lc. #1 $ Lc. #2 $ Lc. #3 $ Interests t be cvered n auts held fr sale: All parties interest in cvered auts Financed party s interest nly in stck fr sale 2. Business Activities 1. List all Lcatin(s) wned r frm which yu perate (use separate sheet if necessary). Please list Address, City, State and descriptin f use. Shw main lcatin as N. 1. NUMBER AND STREET CITY COUNTY STATE ZIP CODE Lc. 1 Lc. 2 Lc. 3 a. Descriptin f Use 1. Lc. 1: Type f Facility: Building Strage Standard Open Lt (Prtected Psts/Chains) Nn-Standard Open Lt (Unprtected) 2. Lc. 2: Type f Facility: Building Strage Standard Open Lt (Prtected Psts/Chains) Nn-Standard Open Lt (Unprtected) 3. Lc. 3: Type f Facility: Building Strage Standard Open Lt (Prtected Psts/Chains) Nn-Standard Open Lt (Unprtected) UDA-A DEC2012 Page 3 f 7

4 2. Describe test drive prcedures: 3. Are custmers allwed t keep cars vernight r weekends? Yes N 4. Lts a. If auts are utside, is lt a prtected lt that is cmpletely enclsed by a chain link fence r chain and psts nt mre than fur feet apart? Yes N b. Is lt cmpletely enclsed by a chain link fence r chain and psts nt mre than six feet apart? Yes N c. Is lt cmpletely fldlighted? Yes N d. D yu use guard dgs? Yes N e. Is their plice r ther prtectin? Yes N f. D yu pick up r deliver autmbiles? Yes N g. D yu repssess prperty auts? Yes N 1. Number f repssessins annually # 5. Estimated annual grss receipts: $ a. Retail Sales: $ 6. If yu are a whlesaler, d yu maintain a separate strage facility? Yes N If yes, please explain: 7. D yu cnsign auts t retail dealers? Yes N If yes, hw are they insured? 8. Average number f vehicles sld annually: Ttal: Retail: Whlesale: 9. Indicate hw many: a. Dealer plates: 100% used fr business. N persnal use is insured. b. Transprtatin Plates: 100% used fr business. N persnal use is insured. c. Service Vehicles: 100% used fr business. N persnal use is insured. 10. Hw are auts acquired? Lcal aut auctin % New car dealer % Whlesale % Private Parties % UDA-A DEC2012 Page 4 f 7

5 11. Average number f cars fr sale at ne time: 12. List any majr auctins yu attend in rder f mst frequented: Auctin # City/State 13. Please cmplete a Schedule f Named Operatrs, listing drivers t be specifically insured (n cverage will be affrded unless all drivers wh are furnished an aut are listed). Include any emplyee r prprietr, partner r fficer wh is t be named as an Insured Driver n cvered auts. Nte: Insurance is prvided t named peratrs nly. Specifically, insured cverage fr named insured peratrs is limited t business use nly. Persnal use f insured vehicles--wned r nn-wned--is EXCLUDED. All business wners and emplyees must purchase a separate family aut plicy fr persnal use f wned and nn-wned vehicles. 14. Please cmplete a schedule f Cmmercial Vehicles t be specifically insured. Please list all vehicles wned and licensed by yu and used in yur business. Include all service vehicles, tw trucks, and car carriers. N cverage will be affrded unless each unit is specifically listed, described, and insured, and a cverage charge is paid. Scheduled vehicles are nly insured when driven by named insured drivers. 3. Emplyee Infrmatin a. Number f Ttal Staff Full Time Part Time Seasnal NUMBER A. Prprietr, Partner, Officer $ B. Office Emplyees $ C. Salesmen $ D. Service Dept. Emplyees $ E. Other Emplyees $ ESTIMATED ANNUAL GROSS PAYROLL b. Schedule f drivers furnished Auts. Please list all drivers accrding t their emplyee class. Nte: N cverage affrded unless all drivers wh are furnished an Aut are listed. Class I: Furnished vehicles fr persnal use (minimum age f driver is 23 years). Class II: Furnished vehicles fr business use nly (minimum age f driver is 23 years). UDA-A DEC2012 Page 5 f 7

6 c. Class I- Emplyees: Persnal Use Any emplyee r active prprietr partner f fficer wh is furnished a cvered Aut. NAME POSITION D.O.B. DRIVERS LICENSE # STATE Inactive prprietrs, partners r fficers r family members f active r inactive prprietrs, partners, fficers r emplyees whm yu will allw t drive an Aut, r ther persn r rganizatin wh yu furnish an Aut. NAME POSITION/ RELATIONSHIP D.O.B. DRIVERS LICENSE # STATE d. Class II- Emplyees: N persnal use Prprietrs, partners and executives active in the business, salespersns, general mangers, service managers, and any emplyee wh drives Auts, but wh is nt furnished an Aut. NAME POSITION D.O.B. DRIVERS LICENSE # STATE REPRESENTATIONS AND WARRANTIES The Applicant is the party t be named as the "Insured" in any insuring cntract if issued. By signing this Applicatin, the Applicant fr insurance hereby represents and warrants that the infrmatin prvided in the Applicatin, tgether with all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin, is true, crrect, inclusive f all relevant and material infrmatin necessary fr the Insurer t accurately and cmpletely assess the Applicatin, and is nt misleading in any way. The Applicant further represents that the Applicant understands and agrees as fllws: (i) the Insurer can and will rely upn the Applicatin and supplemental infrmatin prvided by the Applicant, and any ther relevant infrmatin, t assess the Applicant s request fr insurance cverage and t qute and ptentially bind, price, and prvide cverage; (ii) the Applicatin and all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin are warranties that will becme a part f any cverage cntract that may be issued; (iii) the submissin f an Applicatin r the payment f any premium des nt bligate the Insurer t qute, bind, r prvide insurance cverage; and (iv) in the event the Applicant has r des prvide any false, misleading, r incmplete infrmatin in cnjunctin with the Applicatin, any cverage prvided will be deemed vid frm initial issuance. The Applicant hereby authrizes the Insurer and its agents t gather any additinal infrmatin the Insurer deems necessary t prcess the Applicatin fr quting, binding, pricing, and prviding insurance cverage including, but nt limited t, gathering infrmatin frm federal, state, and industry regulatry authrities, insurers, creditrs, custmers, financial institutins, and credit rating agencies. The Insurer has n bligatin t gather any infrmatin nr verify any infrmatin received frm the Applicant r any ther persn r entity. The Applicant expressly authrizes the release f infrmatin regarding the Applicant s lsses, financial infrmatin, r any regulatry cmpliance issues t this Insurer in cnjunctin with cnsideratin f the Applicatin. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a qute with a Sublimit f liability fr certain expsures, (ii) qute certain cverages with certain activities, events, services, r waivers excluded frm the qute, and (iii) ffer several ptinal qutes fr cnsideratin by the Applicant fr insurance cverage. In the event cverage is ffered, such cverage will nt becme effective until the Insurer s accunting ffice receives the required premium payment. UDA-A DEC2012 Page 6 f 7

7 The Applicant agrees that the Insurer and any party frm whm the Insurer may request infrmatin in cnjunctin with the Applicatin may treat the Applicant s facsimile signature n the Applicatin as an riginal signature fr all purpses. The Applicant acknwledges that under any insuring cntract issued, the fllwing prvisins will apply: 1. A single Accident, r the accumulatin f mre than ne Accident during the Plicy Perid, may cause the per Accident Limit and/r the annual aggregate maximum Limit f Liability t be exhausted, at which time the Insured will have n further benefits under the Plicy. 2. The Insured may request the Insurer t reinstate the riginal Limit f Liability fr the remainder f the Plicy perid fr an additinal cverage charge, as may be calculated and ffered by the Insurer. The Insurer is under n bligatin t accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has n bligatin t ntify the Insured f the pssibility that the maximum Limit f Liability may be exhausted by any Accident r cmbinatin f Accidents that may ccur during the Plicy Perid. The Insured must determine if additinal cverage shuld be purchased. The Insurer is expressly nt bligated t make a determinatin abut additinal cverage, nr advise the Insured cncerning additinal cverage. 4. The Insurer is herein released and relieved frm any and all respnsibility t ntify the Insured f the pssible reductin in any applicable Limit f Liability. The Insured herein assumes the sle and individual respnsibility t evaluate, cnsider, and initiate a request fr additinal cverage r reinstatement f the annual aggregate Limit f Liability which may be exhausted by any single Accident r cmbinatin f Accidents during the Plicy Perid. Dated: Applicant: Dated: Agent/Brker: Signature Signature Print Name Print Name UDA-A DEC2012 Page 7 f 7