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Insurance Form
First name
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Expiration Date of Current Insurance Policy
Expiration Date of Current Bond
Business Name
Business Legal Entity:
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Individual
Partnership
Limited Liability Corporation
Corporation
Is your business mobile in nature?
Yes
No
Location where you conduct Garage Operations:
Address
City
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State
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Vermont
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West Virginia
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Zip Code
Has your insurance been cancelled or non-renewed within the past three years?
Yes
No (n/a in MO)
Do you have or maintain animals on your premises?
Yes
No
If yes, please list type and breed
Are they pets or security?
Pets
Security
Do you have or maintain firearms on your premises?
Yes
No
Do you participate in any ride share programs?
Yes
No
If yes, please explain
List your total annual gross receipts from
Auto Sales
$
Auto Service/Repair
$
Retail product sales
$
Uninstalled part sales
$
Any other operations
$
What are your hours of operation?
Dealer Information
What type of dealer license do you hold?
Retail
Wholesale
Dealer License Number
State
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Percentage of New auto sales
Percentage of Used auto sales
Do you conduct auto auctions?
Yes
No
What percent of your auto sales are?
Do you operate a salvage lot?
Yes
No
N/A
Do you use a consignment agreement for consigned autos?
Yes
No
N/A
Do you operate any auto pawn or title pawn operations?
Yes
No
Number of dealer plates you have
Number of other types of plates you have
And for how long?
Are the keys or any device used to start or operate the auto, left in or upon the auto at any time?
Yes
No
Describe your key controls
During normal business hours
After business hours
When do you transfer the title of a sold auto?
Please select
At time of sale
When the state transfers title
When auto is paid for in full
Other
Do you pick up, deliver, or transport autos not owned by you?
Yes
No
Do you repossess autos for yourself?
Yes
No
For others?
Yes
No
Do you export autos to other countries?
Yes
No
Do you loan or lease autos?
Yes
No
If yes, for what purpose?
On test drives do you always
Obtain a copy of the customer’s drivers license and proof of insurance?
Yes
No
Ride along with the customer?
Yes
No
Explain No answers:
Do you allow overnight test drives?
Yes
No
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