If checked, please complete the False Pretense/Identity Theft Supplemental Application.
Dealers Open Lot Application 011121 Page 1 of 5 RSGprograms.com
National Specialty Programs
Toll-Free:
800-366-5810 Fax: 410-828-8179
Contact us: programs
@ryansg.com
Dealers Open Lot Application
Agency Name: _________________________________________________________________________________ ___________________________
Agency Address: __________________________________________________________________________________________________________
Phone: _________________ _____________ Fax: ______________________________ Email: __________________________________
Agency Contact: _________________________________________________________________________________________ _________________
1. Named Insured: ________________________________________________________________________________________________________
(Complete name as it should appear on the policy including Inc., Corp., Ltd., Etc.)
2. Mailing Address: _________________________________________________________________________________ ______________________
**Please make certain for any locations not included below that they are added using the Continued Locations Schedule (page 4 of this application).
3. Inspection Contact & Claims Contact: ________________________________________________ Email: __________________________
4. Telephone: _____________________________
5. Website: _______________________________ FEIN: ______________________________
6. Year established: ________________________
7. Policy proposed effective date: __________________ to ___________________
8. Current Comp & Coll Deductibles: ______________________________ Current Weather Deductible: ______________________________
9. Deductibles:
a. Comp: $1,000/$3,000 $1,500/$5,000 $2,500/$10,000 $5,000/$15,000 10,000/$25,000
b. Collision: $1,000/$3,000 $1,500/$5,000 $2,500/$10,000 $5,000/$15,000 10,000/$25,000
10. Type of Franchise(s): ____________________________________________________________ ________________________________________
11. a. Comprehensive Inventory Limits: (include new, used, owned, furnished, service & shop rentals and lease returns)
Location & Address:
Location Description
Policy Limit (up to 130% over
the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
1.
2.
3.
4.
5.
b. Collision Inventory Limits:
Location & Address:
Location Description
Policy Limit (up to 130% over
the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
1.
2.
3.
4.
5.
12. False Pretense Policy Aggregate Limit: $100,000 $250,000
Do they require titles prior to taking possession of the vehicles?
Dealers Open Lot Application 011121 Page 2 of 5
RSGprograms.com
13. Stated Amount Vehicles:
Vehicle Description Year, Make, Model
Vin #
Value
Owner of vehicles
1.
2.
14. Is Earth Movement coverage included on the expiring policy? Yes No
If yes, what Limits/Ded: ____________________________
Does the dealer utilize rooftop parking or have a multi-level parking structure for their inventory? Yes No
If yes, # of units: __________ Maximum value: __________________
15. Does the dealer have vehicles on the lot with values greater than $250,000? Yes No
If yes, please attach a list of specific vehicles.
16. Lot Protection (check all that apply):
Post & Chain Gated Entrance Completely enclosed by fencing Guard Rail
Security Guard Local Patrol Overnight Lighting Trenching
Video Surveillance Guard Dogs Lo Jack Other: _______________________
17. Are any of the above locations within 10 miles of the coast or wit hin 500 feet of a Flood Zone? Yes No
If yes, please forward an emergency weather/evacuation plan and/or a flood avoidance plan.
18. Key Controls (check all that apply): Vehicle Lock Boxes* Peg Board Key Cabinet
Key Track (or similar) System Other: _______________________
*a. If dealer uses vehicle lock boxes, describe the type of lock box utilized: _______________________________________________________
If yes, are keys removed at night? Yes No
b. Managers must approve/record the duplication of keys? Yes No
c. Extra sets of keys are locked away with limited access? Yes No
d. Is it standard practice to leave the keys in dealer vehicles? Yes No
e. Are keys kept away from public access? Yes No
f. Are the working set of keys maintained in the control of the salesmen during all sales transactions and
customers test drives? Yes No
19. Furnished Vehicles:
Total # of Furnished Vehicles (Demos) provided to owners and empl oyees: ___________
Total # of Furnished Vehicles provided to non-employees. Provide list if non family: _________________ __
Are all non-employees with Furnished Vehicles over the age of 25? If no, attach explanation. Yes No
Does the dealer utilize a demo agreement? (Please attach copy.) Yes No
20. Parts, Trucks & Service Loaners:
Total # of Parts: _____________ Trucks: _______________
Total # of Service Loaners provided to customers: _____________
Does dealer utilize a customer loaner form? (Please attach copy.) Yes No
Is there a minimum age requirement? Yes No
If yes, please describe: ________________________________________________________________________ _____________________
21. Does the dealer review employees motor vehicle reports at the time of hire and annually? Yes No
22. Does the dealer follow written standards for acceptable MVR’s? Yes No
23. How often is there a physical audit of inventory? ______________________________________________________
24. Are customers licenses verified for validity including two forms of ID’s and copied prior to test drives? Yes No
If no, what steps are taken to prevent theft of the vehicle? ____________________________________________________________________
____________________________________________________________________________________________________________________
25. Does sales staff accompany prospective customers on test drives? Yes No
If no, what is the percentage of time? _______________________
26. Does the dealer work with wholesalers? Yes No
If yes, do they require banker’s or cashier checks prior to delivery of titles? Yes No
Yes No
Dealers Open Lot Application 011121 Page 3 of 5
RSGprograms.com
Additional Comments: _____________________________________________________________________________________________________
Additional Named Insureds: ________________________________________________________________________________________
_____________________________________ ___________________________________________________________________________________
Loss Payee/Lienholder Information:
Lienholder’s Name:
Address:
Location #
Interest in Dealership
Lienholder’s Name:
Address:
Location #
Interest in Dealership
Prior Carrier Information
Policy Year
YR:
YR:
YR:
YR:
YR:
Carrier:
Premiums:
Policy Limit:
Current Information
1. Has any company canceled or declined to renew in the past 5 years? Yes No
If yes, please explain: _____________________________________________________________________ _____________________________
2. Has the insured ever had a lapse in coverage? Yes No
If yes, please explain: __________________________________________________________________________________________________
3. Has the dealer experienced Bankruptcy, Financial Reorganization/Attachment or Lien in the past 5 years? Yes No
Claim Information
1. Make sure to attach 5 years of currently valued loss runs. (Valued no more than 3 months from date of application.)
2. Do you require staff to report all unusual incidents and are all incident reports reviewed by Management? Yes No
3. Do you have any knowledge concerning any incidents that have occurred prior to the date of this application that
may give rise to a future claim? Yes No
NOTICE TO APPLICANTS: THIS APPLICATION MUST BE COMPLETED IN FULL AS THE QUOTE WILL BE BASED SOLELY ON THE INFORMATION PROVIDED.
Fraud Warning Notice
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR
INSURANCE CONTAINING FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT
MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME BY SIGNING THIS APPLICATION, THE SIGNOR WARRANTS THAT
TO THEIR BEST KNOWLEDGE ALL INFORMATION GIVEN IS TRUE AND ACCURATE. IN COLORADO, THE DISTRICT OF COLUMBIA, LOUI SIANA, MAINE,
TENNESSEE, AND WASHINGTON, INSURANCE BENEFITS MAY ALSO BE DENIED.
__________________________________________ _________________________________________ ______________________
Name (type or print) Signature Date
__________________________________________
Dealer/Officer Name (type or print)
__________________________________________ _________________________________________
Agent Name (type or print) Signature
click to sign
signature
click to edit
click to sign
signature
click to edit
Dealers Open Lot Application 011121 Page 4 of 5
RSGprograms.com
Continued Location Schedule
Comprehensive Inventory Limits: (includes new, used, owned, furnished, service &
shop rentals and lease returns.)
Location & Address:
Location Description
Policy Limit (up to 130%
over the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
6
$
$
7
$
$
8
$
$
9
$
$
10
$
$
11
$
$
12
$
$
13
$
$
14
$
$
15
$
$
16
$
$
17
$
$
18
$
$
19
$
$
20
$
$
Collision Inventory Limits:
Location & Address:
Location Description
Policy Limit (up to 130%
over the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
6
$
$
7
$
$
8
$
$
9
$
$
10
$
$
11
$
$
12
$
$
13
$
$
14
$
$
15
$
$
16
$
$
17
$
$
18
$
$
19
$
$
20
$
$
Dealers Open Lot Application 011121 Page 5 of 5
RSGprograms.com
Continued Location Schedule
Comprehensive Inventory Limits: (includes new, used, owned, furnished, service &
shop rentals and lease returns.)
Location & Address:
Location Description
Policy Limit (up to 130%
over the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
21
$
$
22
$
$
23
$
$
24
$
$
25
$
$
26
$
$
27
$
$
28
$
$
29
$
$
30
$
$
31
$
$
32
$
$
33
$
$
34
$
$
35
$
$
Collision Inventory Limits:
Location & Address:
Location Description
Policy Limit (up to 130%
over the Average 12 Month)
Average 12 Month Insurable
Inventory Value ($)
21
$
$
22
$
$
23
$
$
24
$
$
25
$
$
26
$
$
27
$
$
28
$
$
29
$
$
30
$
$
31
$
$
32
$
$
33
$
$
34
$
$
35
$
$
RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary
of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some
products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516).
©2021 Ryan Specialty Group, LLC