contract rental car 

Home Office:

Madison, Wisconsin

 

Administrative Office:

 

8877 North Gainey Center Drive • Scottsdale, Arizona 85258

 

1-800-423-7675 • Fax (480) 483-6752

 

DAILY AUTO RENTAL APPLICATION

 

1. NAME AND ADDRESS OF APPLICANT:

 

Applicant Name: 

 

D/B/A (if any): 

 

Telephone:   Fax: 

 

Mailing Address: 

 

City, State, Zip:   County: 

 

Web Site: 

 

Applicant is: ☐ Individual ☐ Partnership ☐ Corporation ☐ Other: 

 

We require the registered owner’s:

 

Federal Employer Identification Number (FEIN)  ; or

 

State Customer Number for all vehicles  .

 

2. Year Business Started: 

 

Name of Owner(s)/Manager(s)/Risk or Claim Manager(s)          No. of Years in Rental Business Positions Held/Company

                                 

                                 

                                 

3. Are any of the vehicles to be insured provided for personal use? ☐ Yes  ☐ No

 

If yes, list drivers: 

 

4. Is Drive Other Car Coverage needed for any owners or managers?  ☐ Yes  ☐ No

 

If yes, list:

 

5.            Location Addresses        No. of Cars         No. of Trucks     Manager             Type

(Airport, Hotel, Retail)

                                                                                 

                                                                                 

                                                                                 

(If more than three locations, use separate sheet to provide this information.)

 

6. Does applicant have operations other than short-term auto rentals (long-term leasing, used car sales, etc.)? ☐ Yes  ☐ No

 

If yes, list: 

 

 

 

7. Are any vehicles furnished for promotional, advertising or charitable use? ☐ Yes  ☐ No

 

If yes, please provide details:

8. Do you check MVRs prior to hiring employees who may drive rental vehicles or shuttle buses? ☐ Yes  ☐ No

 

9. Do you have any special contracts to provide vehicles for preferred customers (Military, Government, Corporate)? ☐ Yes  ☐ No

 

If yes, please explain (including limits provided):

10. Are you engaged in any of the following operations:

 

Long-Term (more than twelve [12] months) Leasing? ☐ Yes  ☐ No

 

Used Car Sales? ☐ Yes  ☐ No

 

“Rent to Own” Rentals? ☐ Yes  ☐ No

 

Motorcycle Rental? ☐ Yes  ☐ No

 

Trailer Rentals? ☐ Yes  ☐ No

 

Equipment Rental? ☐ Yes  ☐ No

 

Motorhome Rental? ☐ Yes  ☐ No

 

Dealership Sales or Service? ☐ Yes  ☐ No

 

Recreational Vehicle Rental? ☐ Yes  ☐ No

 

If yes, how are these operations insured?

11. CURRENT COVERAGE:

 

Carrier:   Policy Period:   to 

 

Rating Basis:   Rate: 

 

Current Liability Limits: Requested Liability Limits:

Owner:                Owner: 

Renter:                Renter: 

Corporate Acct.:              Corporate Acct.: 

UM/UIM:   PIP:                UM/UIM:   PIP: 

Current Physical Damage:           Requested Physical Damage:

      Yes No

 

      Yes No

 

Comprehensive? ☐ ☐ Deductible        Comprehensive? ☐ ☐ Deductible 

Collision? ☐ ☐ Deductible        Collision? ☐ ☐ Deductible 

Other:   Deductible         Other:   Deductible 

Have you had any insurance canceled, declined or nonrenewed in the last three years? (not applicable in Missouri) ☐ Yes  ☐ No

 

If yes, explain:

12. TYPE OF RENTAL: Personal  % Military  % Business  % Corporate Acct.  %

 

Insurance Replacement  % International Customers  %

 

What is the average length of rental? 

 

 

 

13. ACTIVITY FOR PAST TWELVE (12) MONTHS (Time and Mileage Only):

 

                Receipts              No. of Cars         No. of Trucks                                    Receipts              No. of Cars         No. of Trucks

JAN                                                                       JUL                                         

FEB                                                                       AUG                                      

MAR                                                                     SEP                                        

APR                                                                      OCT                                       

MAY                                                                     NOV                                      

JUN                                                                      DEC                                        

Projection for next twelve (12) months: Gross Receipts: $  Average Number of Units: 

 

14. EXPOSURE DATA:

 

Previous Experience (Past three full years plus current):

 

Policy Period     Gross 

Receipts              Average Number of Units           Carrier

Cars       Trucks

                                                                 

                                                                 

                                                                 

                                                                 

15. COUNTER PRACTICES:

 

Minimum Age:   Maximum Age: 

 

Military Rental Requirements: 

 

Percentage of Cash Rentals:  % Percentage of Credit Card Rentals:  %

 

Are credit cards required on all rentals? ☐ Yes  ☐ No

 

Are additional drivers listed on rental agreement? ☐ Yes  ☐ No

 

Are additional drivers’ requirements same as renters’? ☐ Yes  ☐ No

 

Is driving record questionnaire completed by renter? ☐ Yes  ☐ No

 

Is MVR screening system used at counter? ☐ Yes  ☐ No

 

Is renter’s insurance information verified prior to rental? ☐ Yes  ☐ No

 

Are vehicles used to carry passengers for hire? ☐ Yes  ☐ No

 

Do you have a Counter Agent Training Program? ☐ Yes  ☐ No

 

On local and cash rentals, do you verify employment, residence address and credit references? ☐ Yes  ☐ No

 

Do you allow vehicles to be taken to Canada? ☐ Yes  ☐ No

 

Do you allow vehicles to be taken to Mexico? ☐ Yes  ☐ No

 

Are there any territorial restrictions? ☐ Yes  ☐ No

 

If yes, describe:

Do you offer Supplemental Liability Insurance (SLI, LIS or RLI) to the renter? ☐ Yes  ☐ No

 

If yes, what percentage of your rentals include SLI, LIS or RLI?  %

 

Is coverage: ☐ primary, or ☐ excess? Name of Insurance Carrier: 

 

Attach copy of coverage form.

 

 

 

Do you offer Collision Damage Waiver (CDW, LDW)? ☐ Yes  ☐ No

 

If yes, what percentage of your rentals include CDW, LDW?  %

 

Do you pick up and/or deliver vehicles to rentees? ☐ Yes  ☐ No

 

16. FLEET PROFILE AND MAINTENANCE (average number or percentage):

 

Private Passenger:   Motorhomes:   Trucks: 

 

Exotic:   Full-Size Vans:   Service Vehicles: 

 

Pickups:   Cargo Vans:   Shuttle Buses: 

 

Do you have a formal Fleet Maintenance and Safety Program? ☐ Yes  ☐ No

 

If yes, attach a detailed description.

 

Do you keep maintenance records on all units? ☐ Yes  ☐ No

 

Do you use a Service Checklist before each rental? ☐ Yes  ☐ No

 

Is your storage lot secured? ☐ Yes  ☐ No

 

Please describe:

Do any of your vehicles have anti-theft devices or other special equipment? ☐ Yes  ☐ No

 

Please describe:

17. FILINGS

 

Are state filings required? ☐ Yes  ☐ No

 

If yes, provide your docket number and base state: 

 

Show exact name and address in which permits are to be issued:

Are there any special requirements needed for City permits, Certificates of Insurance, oversize and/or overweight permits? ☐ Yes  ☐ No

 

If yes, provide details:

The following information must be included with each application:

 

(1) Copy of rental agreement and all addendums.

 

(2) Current fleet list with year, make, model, VIN and state of vehicle registration.

 

(3) Insurance company loss runs for current and prior three years.

 

(4) Drivers List of all employees, including DOB and License number.

 

(5) Attach any Loss Payees, Additional Insureds or Certificate Holders required.

 

This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

 

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (Not applicable to Nebraska, Oregon or Vermont).

 

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for 

the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

 

WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to 

an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the 

applicant.

 

Notice To Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any in-surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

 

APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

 

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

Notice To Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

 

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

 

NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

 

NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

 

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a 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 connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

 

APPLICANT’S NAME AND TITLE: 

 

APPLICANT’S SIGNATURE:   DATE: 

 

(Must be signed by an active owner, partner or executive officer)

 

PRODUCER’S SIGNATURE:   DATE: 

 

Agent’s Name: 

 

Address: 

 

Telephone: ( )  Fax: ( )

 

AGENT NAME:   AGENT LICENSE NUMBER: 

 

(Applicable to Florida Agents Only.)

 

IOWA LICENSED AGENT: 

 

(Applicable in Iowa Only)

 

                IMPORTANT NOTICE    

                 

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning 

character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

 

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