Auto Dealer Supplemental Application The following items have been identified as important to our underwriting of franchised auto dealers. Some of these require a simple yes or no answer and some will require a narrative response. This application must be completed when sending in a new submission or renewing a policy.
General Dealership Information
1. Date of Application: 2. Name of Dealership: 3. Federal ID#: 4. Proposed Effective Date: Class I Employees:
Class I Regular Operators are any Employees whose principal duty involves the operation of covered autos; Demos, Parts Drivers, Valet Drivers, Courtesy Drivers and or any employee who is furnished demos such as Salespersons. 5. Number of Regular OperatorsPart TimeFull Time
6. All Other Operators Part Time Full Time Class II Non Employees:
Any of the following persons who are regularly furnished with a covered auto: Inactive-Proprietors, Partners or Officers and their relatives and the relatives of any person described in Class I. 7. Number of Employees Under Age 25 All Others 8. Names of Owner(s)/Principal(s): Active
9. Name of person responsible for Deductible Recoveries: Telephone No.: Email: 10. Management has suitable industry/management experience:YesNo
Explain:
11. Date Franchise Established:12. Franchise(s) held:
13. Operations Include: New Car Sales Used Car Sales Body Shop Service
14. What percentage of Gross Sales are derived from: New Car Sales % Used Car Sales %
Service % Other: %
15. Other operations on the facilities: 16. Maximum number of vehicles used in business:
Wreckers/Rollbacks (Owned): Service Trucks:
Parts Delivery Vehicles: Rental Vehicles: 17. Maximum Number of Vehicles provided To or For (Include copies of written agreements used):
Owners: Managers: Employees: Non-Employees:
18. Provide a narrative on Demo Privileges. What type of employee is allowed a demo? Attach Demo Agreement: 19. Please describe relationship for all Non Employee Demo Drivers: 20. List names of ALL individuals or organizations that the dealership loans vehicles on a long or short
term basis (i.e. daily, weekend, etc). That includes politicians, university officials, professional
athletes, high schools, etc. PLEASE NOTE THESE INDIVIDUALS WILL BE RATED AS NON
EMPLOYEES ON YOUR POLICY AND PREMIUM WILL BE CHARGED.
Last Name First Name License (No., State) DOB
FOR CONSIDERATION OF THIS APPLICATION OF INSURANCE PLEASE PROVIDE CERTIFICATES OF INSURANCE FROM ABOVE INDIVIDUALS OR ORGANIZATIONS NAMING APPLICANT ADDITIONAL INSURED.
21. Number of Employees in the Following Classifications (as of the date of this application):
22. New Employee Selection Procedure Used Prior to Hiring:
Please provide copy of MVR Program. Check procedures that are applicable. Does written procedure exist? Yes No
If yes, has the procedure been reviewed by a labor attorney? Yes No
Approved Application Form Yes No Telephone background check Yes No
Motor Vehicle check Yes No Personal interview witnessed Yes No
References checked Yes No Road test given Yes No
Drug screening test required Yes No Other: Yes No
Customer Use of Dealer Owned Vehicles:
23. Are vehicles test driven without employee in vehicle? Yes No If yes, please explain below under what circumstances an employee would not accompany the customer. Note:Test drive accidents are less likely to happen if customer is accompanied by an employee.
Explanation:
24. Is there a predetermined route established for Customer Test Drives and recently serviced vehicles? Yes No If yes, please describe the route below. Note: Statistics show a route mainly consisting of right hand turns is less likely to lead to an accident.
Customer Use of Dealer Owned Vehicles continued: Is Customer’s driver’s license checked? Yes No Is copy made? Yes No
Proof of insurance required? Yes No Is copy made? Yes No
Is Customer’s insurance verified? Yes No 25. Are vehicles loaned or rented to service or repair customers? Yes No
If yes, explain in specific detail below. Note: Loaned vehicles create a large liability exposure to your dealership, recommending a car rental operation instead (i.e. Budget, Hertz, Enterprise) eliminates this exposure.
Attach copy of Loaner Agreement
26. Do you allow 24 hour Test Drives? Yes No If yes, Do you have a specific insurance policy covering this exposure? Yes No
What is the name of the carrier?
What are your Limits of Insurance? Please attach a copy of the policy.
27. Control of Customer Vehicles in Your Care:
Maximum number of Customer’s Cars on premises at any one time:
Maximum value of Customer’s vehicles on premises at any one time: $
How are vehicles protected? Check all that apply.
Fenced lots with lockable gates Watchmen Alarm Systems
Key Control – Describe:
Are all customer vehicles protected by the above? Please describe under what circumstance a customer’s vehicle would not be protected by the above: Do you take cars on consignment? Yes No
Do you confirm these vehicles have Physical Damage coverage? Yes No
Note: Certificates of Insurance should be obtained from consignee. 28. Service and Repair Operations:
Is the public barred from the service area? Yes No
Service and Repair Operations continued: Are signs posted to that effect? Yes No
Note: Extremely large losses can result from customers entering service areas. Please type or write below what posted signs state.
Please describe in detail how you handle customer complaints:
Do you have an arbitration agreement with clients to resolve possible disputes? Yes No
Do you video tape any transactions with customers? Yes No If yes, what type of transactions?
Are Technicians factory trained? Yes No What technicians are ASE Certified?
Name: Name:
Name: Name: Repairs checked by Supervisor and/or Service Manager? Yes No
Does service order contain a “Hold Harmless” clause for personal articles left in vehicles? Yes No
Does Applicant perform vehicle conversions? Yes No
Is location to be insured in a heavily traveled area? Yes No
Does Applicant own a sponsor a car for racing? Yes No
Does Applicant perform any tire recapping or retreading? Yes No
Does Applicant operate a
Motorcycle sales operation? Yes No RV sales operation? Yes No
Public service gas station? Yes No Public storage and/or parking garage? Yes No
Public car wash? Yes No Public Towing Operation Yes No
Salvage operation Yes No Own or operate any water or aircraft Yes No
Are parking areas and traffic flow lanes clearly defined? Yes No
Are surfaces of steps, ramps and floors properly treated to prevent slips and falls? Yes No Are customer entrance and exit ramps built to code? Yes No
Below are listed the Coverages available under the Edward E. Hall Auto Dealer Program that are not ISO based. Please check the Coverages desired. All Limits are in the aggregate.
Coverages Limits Quoted
(Higher limits are available for additional charge)
Insurance Agents E&O
$300,000 In the Aggregate
Odometer E&O
$300,000 In the Aggregate
Truth in Lending E&O
$300,000 In the Aggregate
Automobile Title E&O
$300,000 In the Aggregate
Automobile Dealers Legal Defense & Product Related
g. Encrypt all sensitive and personally identifiable information Yes No
h. Total number of vehicles sold annually? New: Used:
i. What is the average cost of vehicles sold? New:Used: 32. List of Named Insureds in addition to the Applicant. Please include addresses and function. Name Address
COVERAGE IS NOT BINDING UNTIL SPECIFICALLY AUTHORIZED BY EDWARD E. HALL AUTODEALER PROGRAM AND THEN ONLY AS OF THE COMMENCEMENT DATE OF SAID AUTHORIZATION AND IN ACCORDANCE WITH ALL TERMS THEREOF, AND THE SAID APPLICANT HEREBY COVENANTS AND AGREES THAT THE FOREGOING STATEMENTS AND ANSWERS ARE A JUST, FULL AND TRUE EXPOSITION OF ALLA THE FACTS AND CIRCUMSTANCES WITH REGARD TO THE RISK TO BE INSURED, INSOFAR AS THE SAME ARE KNOWN TO THE APPLICANT: AND THE SAME ARE HEREBY MADE THE BASIS AND A CONDITION OF THE INSURANCE, AND A WARRANTY ON THE PART OF THE INSURED.
WARNING
NEW JERSEY: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
ALL OTHER STATES: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT THEY ARE FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.”
NEW YORK: “ANY PERSON WHO KNOWLINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNTECTION WITH SUCH APPLICATION OR CLAIM, KNOWLINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDLENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATE CLAIM FOR EACH VIOLATION.”