Owner(s) Full Name(s) *

Legal Company Name *

DBA *

EIN# *

Phone# *

Email *

Business Address *

Mailing Address (If Different)

Current Insurance Carrier *

Policy # *

Expiration Date *

Current Premium *

Retail Percentage *

Wholesale Percentage *

Do you or will you sell Salvage/Rebuilt Vehicles?

Do you or will you export vehicles?

Average whole sale of vehicles *

Multiplied by the number of cars on your lot *

Equals the dealers open lot coverage *

Would you like Dealers Open Lot Coverage for the above-mentioned amount?

Liability Amount Limit requested? *

# Of Dealer Plates? *

Number of years in business? *

Does the owner own any other businesses?

If Yes, name of business *

Type of business?

Does the business have general liability insurance? *

Business Profile *

List all owners, officers, employees, drivers, sub-contractors, and buyers using your license.

Name *	License # *	DOB *	Position *	Issuing State *	Fulltime / Partime *	Personal Use *
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Best day to contact *

Best time to contact?