Lender Contact Information
Lender Name
*
Lender Address, City, State, Zip
Lender Main Contact
*
Contact Email
example@example.com
Lender Details
Data Processor
Collections Software
Notes or Additional Details
Loan Portfolio Information
Loan Portfolio Information
Rows
# of Collateralized Loans
Maximum Loan Term
# of Projected Loans - 12 Months
Auto - Direct
Auto - Indirect
Motorcycles
Watercrafts/Boats
RV's
Mobile Homes
Commercial Auto
Loan Portfolio Information
Rows
$ of Collateralized Loans
$ Largest Loan Amount
$ Average Loan Balance
Auto - Direct
Auto - Indirect
Motorcycles
Watercrafts/Boats
RV's
Mobile Homes
Commercial Auto
Loss Information
The loss information is important so we can provide an accurate sustainable quote based on the trends of the financial institution.
# of Repossessions last 12 months
# of Repossessions prior 12 months
Premium and Loss Information
Rows
Past 12 Months
Prior 12 Months
Written Premium
Earned Premium
Paid Losses
Breakdown of Paid Claims by Type
Program Type and Coverages
Current Provider
Current Program Type
VSI or Blanket Auto
CPI – TRADITIONAL – 12
CPI – HYBRID – MONTHLY
Other
# of CPI Certificates In Force
Was Your Coverage Recently Underwriting or Cancelled? If so, please provide details.
Current Program Structure
What are the Current Coverages in your Program?
Automatic Protection
Physical Damage
Instrument Non Filing
Conversion/Skip
Repo Expense Reimbursement
Other
Coverage Requested in Quote
Requested Program Types Quoted
VSI or Blanket Auto
CPI – TRADITIONAL – 12
CPI – HYBRID – MONTHLY
Other
If Blanket Coverage/VSI is Requested, how will the premium be assessed?
Coverages Requested?
Automatic Protection
Physical Damage
Instrument Non Filing
Conversion/Skip
Repo Expense Reimbursement
Please Provide Details of Requested Coverages
Requested Effective Date
/
Month
/
Day
Year
Date
Requested Limit of Liability
Requested Deductibles
Other requests
Please indicate collateral type requesting coverage
Autos
Motorcycles
RV’s
Boats
Mobile Homes
Personal Property
Commercial Vehicles and Trucks
Process Information
Does your loan agreement require the borrower to carry proof of insurance during throughout the loan term?
YES
NO
At the time of the loan, do you verify insurance coverage?
YES
NO
Do you follow up for an insurance declarations page throughout
YES
NO
Is the name and phone number of the agent or company noted
YES
NO
Signature
Completed By
First Name
Last Name
Date Completed
-
Year
-
Month
Day
Date
Please upload any documents related to your current program
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