GENERAL INFORMATION

LENDER:
    
NUMBER OF BRANCHES:

ADDRESS:

CITY:                     STATE:

ZIP:

PHONE NUMBER:FAX NUMBER:

EMAIL:

EXPOSURE

current NUMBER OF AUTO SECURED LOANS:

DOLLARS OUTSTANDING ON SECURED LOANS:

HOW MANY AUTO SECURED LOANS DID YOU MAKE 
DURING THE LAST 12 MONTHS?

HOW MANY AUTO SECURED LOANS DO YOU EXPECT 
TO MAKE IN THE NEXT 12 MONTHS?

PERCENT DIRECT%        PERCENT DEALER%

DO YOU HAVE DEALERS WHOSE PLAN OF OPERATION 
IS STRICTLY FULL RECOURSE?
YES    NO    PERCENT%

MAXIMUM LOAN TERM IN MONTHS:    

AVERAGE LOAN TERM IN MONTHS:

AVERAGE DELINQUENCY PERCENTAGE:  
  
YTD%    LAST YEAR%    PRIOR YEAR%

DO YOU MAKE SINGLE PAYMENT LOANS?   
 YES    NO

HOW ARE LOANS CALCULATED?  

SIMPLE INTEREST    PRO RATE    RULE OF 78

DO YOU HAVE AN INSURANCE FOLLOW-UP PROGRAM? 
   
YES    NO

PAST EXPERIENCE

NUMBER OF REPOSSESSIONS
YTD    LAST YEAR    PRIOR YEAR

AVERAGE REPOSSESSION DEFICIENCY

 THIS YEAR  $    LAST YEAR $    PRIOR YEAR $

SKIP LOSSES LAST YEAR

$    NUMBER

SKIP LOSSES PRIOR YEAR

$    NUMBER

HAS THIS INSURANCE BEEN CARRIED PREVIOUSLY?

YES    NO

IF YES, WITH WHOM?
(ATTACH EXPERIENCE IF AVAILABLE)

OTHER VEHICLE COVERAGE

HAS ANY APPLICATION FOR SINGLE INTEREST INSURANCE EVER BEEN DECLINED, CANCELLED OR RENEWAL REFUSED?

YES    NO

or complete, print and fax to:
(805) 584-6251