MSA033 (05/15) Page 1 of 1
WHOLESALE AUTO DEALER SUPPLEMENT
(For use in addition to the completion of the Garage Application)
Applicant’s Name: _________________________________________________________
General Information
1. Do you sell autos to the public? Yes No
If yes, explain: ___________________________________________________________________________________
2. Do you operate out of a residence? Yes No
If yes:
a) Do you have a Homeowner’s Liability Insurance Policy? Yes No
3. Where do you purchase vehicles held for sale? (List from most frequent to least)
City & State: __________________________________ City & State: _______________________________________
City & State: __________________________________ City & State: _______________________________________
4. List any additional states where you conduct operations: __________________________________________________
5. Do you take physical possession of all vehicles you purchase? Yes No
If yes:
a) Where are vehicles stored? ____________________________________________________________________
6. Do you hire Contract Drivers to transport vehicles? Yes No
If yes:
a) How many? ______________ How often are they used? __________________________________________
b) Do you: Use different people each time
Use one or more people consistently (if marked, provide their information on the Garage Application)
7. Do you or any of your drivers have out of state driver’s licenses? Yes No
If yes, explain: ___________________________________________________________________________________
Dealer Plates
Loaning or selling of Dealer Plates is prohibited.
1. How many Dealer Plates do you have? ___________
2. How are your Dealer Plates used? ___________________________________________________________________
_______________________________________________________________________________________________
This questionnaire does not bind the Application nor the Company to complete the insurance, but it is agreed that the
information contained herein shall be part of the basis of the contract should a policy be issued. By signing you are
hereby certifying that all information is accurate to the best of your knowledge.
__________________________________ ____________/__________________________
Signature of Agent Date Signature of Applicant
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