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(Please Print)                                  DEALERSHIP INFORMATION

Dealership Name:__________________________________________     ___Individual    ___Corp

                                                                                                                      ___Partnership  ___LLC

Phone #___________________  Cell #_______________________  FAX #___________________

Dealers #____________    Number of D-Tags: _____________    Years in Business ____________

#1 Lot Location: __________________________________________________________________

#2 Lot Location: __________________________________________________________________

Do you work on customers cars?   ____Yes     ____No      ____Occasionally do warranty work only

How many cars a year do you sell?   ______   Average wholesale value per car sold: $_________­_

Is your lot secured?  ____No     ____Chain Link     ____Post with pipe or cable

Do you want physical damage coverage on your cars?  (Open Lot)  ____Yes    ____No

(If yes) How many cars? _______     Total wholesale value of inventory: $____________________

Deductible per car? $__________    Do you want hail coverage? ___Yes    ___No   ___ Maybe

Current Insurance Company ______________________________ Renewal Date ____________

Current Agent/Agency __________________________  Current Prem  ____________________

DRIVER/EMPLOYEE INFORMATION: (Use additional sheet if necessary)

LIST ALL LOSSES IN PAST 3 YEARS:  (Use additional sheet if necessay)

Date _________  Type ________________________________________  Amt Paid ____________

Date _________  Type ________________________________________  Amt Paid ____________

Date _________  Type ________________________________________  Amt Paid ____________

Please grant our agency permission to use this information to provide comparison quotes before your current policy renews by signing below:

_______________________________________________              ________________________      (Owner’s Signature)                                                                                             Date

FAX TO: (316) 685-5717 or mail to Smalley Insurance Agency., 1640 S. Rock Rd, Wichita, KS  6Here's where you can enter in text. Feel free to edit, move, delete or add a different page element.