Fillable Reposessors Application Reposessors Application (Kinsale Insurance)

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Reposessors Application Reposessors Application (Kinsale Insurance)

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  • 47 check-boxes
  • 114 other fields

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Page 1 of 5
REPOSSESSORS ERRORS & OMISSIONS APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Estimated gross receipts in the NEXT 12 months:
2. Gross receipts in the LAST 12 months:
3. List primary customers for which you repossess (written contract or agreement required):
4. Describe repossession procedures in detail, including identification verification. If wreckers are used, advise how many
wreckers are in operation. If drive-away type operation, advise if keys are used or if vehicles are hotwired. Also,
describe how you get to the vehicle being repossessed.
5. Do you use temporary employees to repossess vehicles? Yes No
If “Yes,” how often?
If “Yes,” please describe your hiring requirements:
________
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
6. What percent of the repos are done by you and your employees? Driven: Towed:
7. What percent of the repos are done by an outside source? Driven: Towed:
Total (must equal 100%) Driven: Towed:
8. If others are handling repossessions on your behalf, explain how their insurance coverage is confirmed and what
minimum General Liability & Errors & Omissions limits are required.
_____________
9. Is there a written contract in place with subcontractors? Yes No
10. Estimated annual number of repossessions:
a. Via you and your employees
b. Via Wrecker/Rollback/Haulaway
c. Via Driveaway
11. What percentages of each type of vehicles/equipment are repossessed?
a. Private Passenger Autos %
b. Light Commercial Trucks %
c. Heavy Commercial Trucks %
d. Commercial Trailers %
e. Other(describe): _____ %
f. Total: %
12. Wrecker operation (Select all that apply):
Repossessor
In conjunction with Auto Dealer operation
In conjunction with Garage Service operation
% used to transport customer’s autos
% used on a for hire basis
For hire, servicing public
13. Percentage of methods you use to acquire your wrecker business:
% Rotation-contracted by state/city/local/authority
% Police scanner
% Auto club
% Other (explain):
14. Who notifies owner of the impending repossession?
15. Are police notified? Yes No
16. Do police ever accompany you on a repossession? Yes No
17. Does applicant conduct any other related operations? Yes No
(e.g. Private Detective, Investigation, Collection) If “Yes,” please explain:
18. Are state licensing laws applicable to this operation? Yes No
If “Yes,” please show license number:
19. Does the applicant, any employee, independent contractor, or anyone acting on your behalf carry Yes No
a firearm?
20. How do you handle a confrontation during the repossession?
Page 3 of 5
21. Give brief explanations of applicants and employees’ experiences in this field. List each driver and note what each
employees’ duties are, especially if various operations are conducted:
Name Experience Job Responsibilities
22. Are you a member of a repossession association? Yes No
If “Yes,” which one?
If Contingent Bodily Injury/Property Damage Coverage is requested and you have a storage lot, please answer the
following:
23. What is the average length of time you store a repossessed auto?
24. Do you ever release vehicle to debtor? Yes No
If “Yes,” please describe procedures:
25. a. After inquiry with each person as appropriate, in the last seven (7) years, has any errors & Yes No
omissions, bodily injury, property damage, or general liability claim or suit ever been made
against the Firm or any predecessor firm or any current or former member of the Firm or
predecessor firm?
If “Yes,” how many?
Please attach copies of currently valued Loss Runs from prior carriers.
If “Yes,” complete a separate Supplemental Claim Form for each claim or suit.
b. After inquiry with each person as appropriate, do you know of any circumstances, Yes No
acts, errors or omissions that could result in an errors & omissions, bodily injury, property
damage, or general liability claim?
26. Coverage Requested
Requested Effective Date___________________________ Requested Retroactive Date
(If prior acts coverage is desired, a copy of current policy declarations must be attached. This optional coverage must
not exceed 5 years.)
Limits of Liability: $100,000/$100,000 $300,000/$300,000 $500,000/$500,000
$1,000,000/$1,000,000
Deductible: $1,500 $2,500 $5,000 $10,000
Page 4 of 5
27. Supplemental Information (Use this area to provide additional information about your operations, loss control/risk
management procedures or any other relevant information.)
Question # Additional Information
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
Page 5 of 5
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Reposessors Application Reposessors Application (Kinsale Insurance)

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Completed 15 July 2020

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