RENTAL VEHICLE INSURANCE APPLICATION

RENTAL VEHICLE INSURANCE APPLICATION
IMPORTANT INSTRUCTIONS

Please include the following information along with this application:

* Complete Current Rental Agreement

* Vehicle Schedule (including: value, year, make, model, VIN# and registrations)

* Loss Experience for the past 4 years plus current year, valued within the past 3 months

* Attach any proposed loss payees, additional insureds or certificate holders if applicable.
Are you filling this out on behalf your client?

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgage BrokerOther
Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
A quotation for the coverage requested under this application is needed no later than :

MonthDayYear
Date
A) PLEASE PROVIDE US THE FOLLOWING GENERAL INFORMATION
1. Company Name(include DBA)
2. Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CA Residents - Please review the Privacy Notice for CA Residents @ Lancerinsurance.com
Business Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Name(s) of Principal(s):
Date of Birth

MonthDayYear
Date
4. Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Email
Website:
6. Person to Contact :
7. Telephone number
Please enter a valid phone number.
Mobile number
Please enter a valid phone number.
Fax:
Please enter a valid phone number.
8. Company Applicant is :

Sole ProprietorCorporationPartnershipLLCOther
9. FEIN
10. System Affiliation (if applicable):
11. Number of years in rental business :
12. Is this a start-up operation?

YesNo
A . Have you had any carrental industry experience?

YesNo
B. If Yes, please list company name, position and number of years experience :
13. Do you own or operate any other business?

YesNo
14. Company Name:
15. Nature of Business:
Years in Operation:
16. Are all vehicles register in the Company Name?

YesNo
If No, Please list name and explain
17. Are there any seasonal fluctuations in the rental of vehicles ?

YesNo
If yes, please explain the fluctuation:
18. Do you maintain copies of rental agreements?

YesNo
If yes, how long are the agreements maintained?
19. Provide estimate for upcoming year: No. of vehicles Gross Receipts $

20. LIST LOCATIONS OF ALL RENTAL FACILITIES

	Street	City	State	Zip	# of Vehicles
1
2
3

B) PLEASE TELL US ABOUT YOUR OPERATIONS
RENTERS :
1. Do you pick up and /or deliver vehicles to rental customers?

YesNo
What is the furthest you will travel?
2. Are there any minimum age restrictions for the renters operating your vehicles?

YesNo
Please describe:
3. Please provide rental percentage type for the following categories: Business % Pleasure %
International % Military %
Insurance or Service Replacement % Other%
4. Do you rent vehicles for more than 30 days?

YesNo
What is the longest length of time you will rent a vehicle?
5. Do you ask the purpose of each rental?

YesNo
6. Do ask where the rental vehicle will be travelling?

YesNo
7. Is the rental's driving record questioned at the counter?

YesNo
Please explain the procedures for verifying the renter's insurance :
8. Do you verify renter's insurance?

YesNo
Please explain procedures for verifying the renter's insurance:
9. What percentage of renters have a personal auto policy? %
10. Do you have any special contracts to provide vehicles for preferred customers(Corporate, Government, Police Agencies or Military)?

YesNo
Please describe and include limits provided :
11. Are you currently engaged in any of the following types of rentals :
A. Long term Leasing (more than 12 months)

YesNo
B. "Rent to Own" Rentals

YesNo
C. "Rent it Here - Leave it There" Rentals

YesNo
D. Limousine Rentals

YesNo
E. Peer to Peer Rentals

YesNo
F. Ride Sharing i.e. Uber or Lyft

YesNo
G. Internet Marketing i.e. Craigslist

YesNo
H. Recreational Vehicle Rentals

YesNo
I. Motorhome Rentals

YesNo
If YES to any of these please explain :
12. Please explain financial qualifications procedure at time of rental :
Credit Card % Cash Deposit %
Other %
13. Are rentals vehicles available to be sold?

YesNo
14. Do you have dealer plates?

YesNo
15.Does your vehicle schedule include vehicles with salvaged titles?

YesNo
If, YES what percentage %
EMPLOYEES:
16. Are employees or principles allowed any personal use of vehicle(s) scheduled in this application?

YesNo
If YES, please list drivers :
17. Do you secure a Motor Vehicle Report on a employee?

YesNo
18. Do you have any age requirements for employees who operate rental vehicles?

YesNo
If YES, please explain :
C)PLEASE TELL US ABOUT YOUR MAINTAINCE PROGRAM
1. Describe guidelines used to insure safe vehicle operating condition. If written guidelines are available , please attach to this application.
2. Do you service your own vehicles?

YesNo
If NO, who does?
3. How often are your vehicles normally serviced ?
4. Describe briefly the vehicle maintenance conducted prior to and after rental :
5. Do you have procedures for recalled vehicles?

YesNo
If YES, please explain :
D)PLEASE TELL US ABOUT YOUR INSURANCE HISTORY FOR THE FIVE YEARS
1. Current Insurance Carrier:
2. Policy Effective Date:

MonthDayYear
Date
Expiration Date:

MonthDayYear
Date

	Policy policy	Insurance Company	Amt. of Liability Coverage	Comprehensive & Collision Ded.	Monthly Rate	Annual Premium	No. of Vehicles
1
2
3
4
5

3. Do you offer Supplemental Liability Insurance Coverage?

YesNo
If Yes, who is your current carrier :
4. Current premium is based on:

Per-Car-Per-Month BasisPercentage of Gross Receipts
5. Has any company, during the past three(3) years, cancelled or refused to renew your automobile insurance coverage? (Not applicable in Missouri)

YesNo
If Yes, Please explain:
E) PLEASE TELL US THE AMOUNTS OF INSURANCE COVERAGE YOU REQUIRE
1. Amount of Liability coverage $
2. Uninsured / Underinsured Motorist Coverage (as required by law) $
3. Comprehensive Coverage Deductible Requested ($1,000 minimum) $
4. Collision Coverage Deductible Requested($1,000 minimum) $
5. Other Coverages & Amounts $
6. If Requesting Physical Damage coverage :
A. Do you have any security measures in place to prevent theft?

YesNo
If Yes, Please explain :
B. Do you have a plan to safeguard your vehicles in the event hail, flooding or any other natural disaster?

YesNo
If Yes, Please explain :
C. Do you have any anti theft equipment to prevent theft on your rental vehicles?

YesNo
If Yes, Please explain :
Should be Empty:

RENTAL VEHICLE INSURANCE APPLICATION

A) PLEASE PROVIDE US THE FOLLOWING GENERAL INFORMATION

CA Residents - Please review the Privacy Notice for CA Residents @ Lancerinsurance.com

B) PLEASE TELL US ABOUT YOUR OPERATIONS

RENTERS :

11. Are you currently engaged in any of the following types of rentals :

EMPLOYEES:

C)PLEASE TELL US ABOUT YOUR MAINTAINCE PROGRAM

D)PLEASE TELL US ABOUT YOUR INSURANCE HISTORY FOR THE FIVE YEARS

E) PLEASE TELL US THE AMOUNTS OF INSURANCE COVERAGE YOU REQUIRE

6. If Requesting Physical Damage coverage :