Page 155 - CARS Standard Program

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NAME OF AGENCY:
MAILING ADDRESS:
TELEPHONE NO. (
TYPE OF BUSINESS: CORPORATION NAME OF OWNER(S):
LIC. NO. CITY
STATE 800#
INDIVIDUAL YEARS IN BUSINESS
Recovery Agency Information Form
)
FAX NO. ( PARTNERSHIP
)
IS OWNER(S) LICENSED AND ACTIVE IN AGENCY OWN OR LEASE OFFICE HOW LONG
LIC. NO.
STORAGE FACILITIES: YES NO
PHYSICAL LOCATION: DESCRIBE PROTECTION
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
.
GENERAL LIABILITY: CARRIER NAME OF AGENT:
AMOUNT. $ TEL. NO. ( )
AMOUNT. $ TEL. NO. ( )
AMOUNT $ TEL. NO. ( )
AMOUNT $ TEL. NO. ( )
TEL. NO. ( ) AMOUNT $ TEL. NO. ( ) AMOUNT $ TEL. NO. (
GARAGE LIABILITY:
NAME OF AGENT:
GARAGE-KEEPERS (DIRECT PRIMARY REQUIRED):
CARRIER:
NAME OF AGENT:
DRIVE-AWAY COVERAGE: CARRIER
NAME OF AGENT:
TOW TRUCK COVERAGE: CARRIER
NAME OF AGENT “ON-HOOK” CARRIER NAME OF AGENT:
CLIENT PROTECTION BOND: CARRIER NAME OF AGENT:
CARRIER
)
NOTE: I CERTIFY THAT ALL THE ABOVE IS CORRECT AND THAT INSURANCE COVERAGES APPLY TO COLLATERAL RECOVERY SERVICES.
(SIGNATURE OF OWNER/TITLE)