Dealer Cover Insurance Services

Information submitted herein is held in the strictest of confidence.

Welcome to Dealer Cover's Free Insurance Quote Form. Please fill out all of the following fields, then press the "Submit Request" button at the bottom of the form. We'll process your information as quickly as possible and we'll fax or mail or e-mail your proposal to you. We thank you for this opportunity.

Lenders Single Interest Insurance Application

Product Identification Information:

Financial Institution Name: *

# of Branches:

Address:


street	city	state	zip

Contact Name and Title: *

Contact Phone: * Contact Fax: Contact Email: *

Loan Portfolio Characteristics:

Current number of auto-secured loans: Total of Loan Balances:
Number of auto-secured loans made in last 12 months:
Number of auto-secured loans expected to be made in next 12 months:
Of 3. above: Direct : % Dealer (Indirect): %
Any Dealers making only full-recourse loans? yes no If yes, % of 3. above
Maximum Loan Term: mos. Average Loan Term: mos.
Average Loan delinquency: YTD % Prior Year % 2nd Prior Year
Make any Single Payment or Balloon payment loans? yes no
Interest on Loan is calculated: Simple Interest Pro Rata Rule of 78’s
Make any Open-ended loans? yes no
If Yes, explain:
Do you track borrower insurance on loan collateral? yes no
Is coverage desired on collateral other than autos? yes no

	Watercraft	Recreational Vehicles	Mobile Homes	Motorcycles	Other Chattels
Max. Loan Amount	$	$	$	$	$
Current # of Loans
Total of Loan Balances	$	$	$	$	$
Est. # New Loans Next 12 mos.

Loan Portfolio Experience:

Number of Repossessions: YTD Prior Year 2nd Prior Year
Average Repossession deficiency: YTD $ Prior Year $ 2nd Prior Year $
Skip Losses: Last Year $ # Prior 2nd Prior Year $ #
Has VSI, LSI or CPI coverage been previously provided? yes no
If Yes, vendor or insurer:
Has any prior VSI, LSI or CPI coverage been cancelled or non-renewed by the insurer, or application(s) for such coverage been declined? yes no
(This Question 5. does not apply to Missouri applicants.)

Agent/Broker Information:

Name:

Phone:

Fax:

Email:

Address:


street	city	state	zip

Dealer Cover Insurance Services | 600 Hampshire Road, Suite 210 | Westlake Village, CA 91361