Page 157 - Microsoft Word - NEW 2017 Standard Program.docx

Recovery Agency Information Form

1. NAME OF AGENCY: LIC. NO.
2. MAILING ADDRESS: CITY STATE
3. TELEPHONE NO. ( ) FAX NO. ( ) 800#

4. TYPE OF BUSINESS: CORPORATION PARTNERSHIP INDIVIDUAL
5. NAME OF OWNER(S): YEARS IN BUSINESS
6. IS OWNER(S) LICENSED AND ACTIVE IN AGENCY LIC. NO.

7. OWN OR LEASE OFFICE HOW LONG
8. STORAGE FACILITIES: YES NO .
PHYSICAL LOCATION: DESCRIBE PROTECTION

9. REFERENCES: HAVE PROVIDED SERVICES FOR AT LEAST 3 YEARS FOR THE FOLLOWING LENDERS: (LIST
THREE REFERENCES; NAMES AND PHONE NUMBERS)
1.
2.
3.
(PROVIDE PHOTOCOPIES OF ANY CERTIFIED TRAINING RELATING TO COLLATERAL RECOVERY)

INSURANCE COVERAGES

10. GENERAL LIABILITY: CARRIER AMOUNT. $
11. NAME OF AGENT: TEL. NO. ( )

12. GARAGE LIABILITY: CARRIER AMOUNT. $
13. NAME OF AGENT: TEL. NO. ( )
14. GARAGE-KEEPERS (DIRECT PRIMARY REQUIRED):
CARRIER: AMOUNT $

NAME OF AGENT: TEL. NO. ( )
15. DRIVE-AWAY COVERAGE: CARRIER AMOUNT $
NAME OF AGENT: TEL. NO. ( )
16. TOW TRUCK COVERAGE: CARRIER
NAME OF AGENT TEL. NO. ( )
17. “ON-HOOK” CARRIER AMOUNT $
NAME OF AGENT: TEL. NO. ( )

18. CLIENT PROTECTION BOND: CARRIER AMOUNT $
NAME OF AGENT: TEL. NO. ( )
NOTE: I CERTIFY THAT ALL THE ABOVE IS CORRECT AND THAT INSURANCE COVERAGES APPLY TO
COLLATERAL RECOVERY SERVICES.

(SIGNATURE OF OWNER/TITLE)