SUPPLEMENTAL LIABILITY INSURANCE (SLI)
PROGRAM APPLICATION
Applicant
Name:
Street
Address:
City, State,
Zip:
Billing
Contact
Name:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
Telephone:
Contact:
Telephone:
System affiliation:
Check here if independent:
How many units in your fleet?
Average:
High:
Low:
Any units over 10,000 GVW?
Yes
No
If so, how many?
Any 12-15 Passenger Vans?
Yes
No
If so, how many?
What limit of liability do you provide the rentee on your rental agreement?
Are corporate rentals a higher limit of liability?
Yes
No
If so, what limit?
Indicate % of your business in each category: Personal:
Corporate:
Insurance Replacement:
Military:
Other:
Are your rental contracts numbered?
Yes
No
Are the numbers preprinted on the contracts?
Yes
No
What computer system do you use? (i.e. Bluebird, Orion, ect.):
Describe your driver qualification procedures:
Do you currently sell SLI?
Yes
No
If so, please indicate: Insurance Co/System:
Daily SLI rate paid to Insurance Co. or System:
Average monthly SLI rental days:
Do you offer an SLI brochure to each rentee?
Yes
No
Do you currently sell PAI?
Yes
No
If so, please indicate: Insurance Co/System:
Daily PAI rate paid to Insurance Co. or System:
Average monthly PAI rental days:
Do you offer a PAI brochure to each rentee?
Yes
No
_____________________________________________________________________________
Signature of Applicant
Date
______________________________________________________________________________
Signature of Producer
Date
THE FOLLOWING INFORMATION MUST BE ATTACHED TO THIS APPLICATION:
1)
Current rental agreement.
2)
Current 3 year loss runs from your existing SLI insurance provider.