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Search for:
Car Rental Business Application
Home
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Car Rental Business Application
Car Rental Business Application
Gravity Certs
2023-02-28T11:40:33-07:00
"
*
" indicates required fields
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10
Primary Business Information
Primary Contact Name
*
First
Last
Email
*
Phone
*
Business Name
*
DBA
Business Type
*
- Select -
Individual
Partnership
Corporation
Non-Profit
FEIN
Business Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Vehicle(s) Garaged Address
*
Same as Business Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Years in Business
*
Is this your primary business?
Yes
No
If not, please explain
Date you want the policy to start
*
MM slash DD slash YYYY
General Business Information
Is this a new operation?
*
Yes
No
Is your operation currently for sale?
*
Yes
No
Is your operation seasonal in nature?
*
Yes
No
Has this business ever operated under any other name?
*
Yes
No
Previous Business Name
*
Previous Business Address
*
Estimate of Financial Worth
*
Gross Receipts Last Year
*
Estimate for Coming Year
*
Have you filed for bankruptcy within the last 5 years?
*
Yes
No
Please explain bankruptcy
*
Number of Short-Term Rental Vehicles
Number of Private Passenger Autos
Number of Pick-Ups
Number of Trucks
Number of SUVs
Number of Semi-Trailers
Number of Trailers
Number of Cargo Vans
Number of Other Vehicles
Others (Specify)
Percentage of Private Passenger Vehicles Rented To:
% Personal
Please enter a number from
0
to
100
.
% Military
Please enter a number from
0
to
100
.
% Commercial
Please enter a number from
0
to
100
.
% Insurance Replacement
Please enter a number from
0
to
100
.
Are any vehicles rented for 1 month or more?
*
Yes
No
Please submit details
*
(Which units, to whom, term of rental or lease.)
Are vehicles ever leased with drivers?
*
Yes
No
Attach list of driver(s) information
Please include a complete list of driver(s), vehicle(s) they drive, age of driver, license number, and chargeable accidents during the past three years.
Drop files here or
Select files
Max. file size: 10 MB.
What is the average length of rental? (in days)
*
What are your rules for selecting renters or lessees?
What is the minimum age permitted to rent vehicles?
*
Are additional drivers permitted?
*
Yes
No
How are additional drivers qualified?
*
Do you ask what the vehicle will be used for when driven?
*
Yes
No
Percent Cash Rental
*
Please enter a number from
0
to
100
.
Percent Credit Card Rental
*
Please enter a number from
0
to
100
.
If cash rental, how do you qualify renter?
Do you use an online service giving subscribers credit, driving & criminal history?
*
Yes
No
Who do you use?
*
Are written counter practice procedures furnished to all counter personnel?
*
Yes
No
Please attach copy of counter procedures
Drop files here or
Select files
Max. file size: 10 MB, Max. files: 1.
Are you named as Additional Insured on renter's policy on any vehicles rented?
*
Yes
No
Explain any Additional Insured requirements or why not required
Do you require liability insurance from the rentee?
*
Yes
No
Explain any liability insurance requirements
Do you obtain a certificate of liability insurance on any vehicles rented?
*
Yes
No
Explain certificate of liability requirements
Do you rent or lease vehicles from others?
*
Yes
No
Please explain renting or leasing from others
*
Are any vehicles rented on a "Rent It Here - Leave it There" basis?
*
Yes
No
Are you required to file evidence of insurance with any state or regulatory authority, or any other authority?
*
Yes
No
Please specify the authority(ies)
*
Do you have your own repair shop?
*
Yes
No
What kind of repairs are made?
*
Are rental contracts pre-numbered?
*
Yes
No
How often are rental vehicles serviced?
*
For Commercial Vehicles Only
If you do NOT rent commercial vehicles, please move to the next section.
Percentage of business derived from renting vehicles to individuals hauling their own personal goods or effects
Please enter a number from
0
to
100
.
Percentage of business derived from renting vehicles to individuals for business use
Please enter a number from
0
to
100
.
Are vehicles rented to trucking firms? (truckers hauling for hire)
Yes
No
Percentage of business renting to trucking firms
Please enter a number from
0
to
100
.
Will you rent vehicles to be used to carry passengers for hire?
Yes
No
Are any vehicles rented to hazardous material haulers?
Yes
No
Please explain hazardous material hauling
Previous Three Insurance Carriers
1. Carrier Name
1. Policy Expiration
MM slash DD slash YYYY
1. # Vehicles
1. # Accidents
2. Carrier Name
2. Policy Expiration
MM slash DD slash YYYY
2. # Vehicles
2. # Accidents
3. Carrier Name
3. Policy Expiration
MM slash DD slash YYYY
3. # Vehicles
3. # Accidents
Loss Experience
1. Date of Loss
1. Amount Paid
1. Loss Description
2. Date of Loss
2. Amount Paid
2. Loss Description
3. Date of Loss
3. Amount Paid
3. Loss Description
Have you ever been declined, cancelled, or non-renewed for this kind of insurance?
*
Yes
No
Please specify date and why
*
Are you or any applicant aware of any facts or past incidents, circumstances, or situations which could give rise to a claim under the insurance coverage sought in this application?
*
Yes
No
Please provide complete details
*
Insurance Needs
Bodily Injury Per Person
- Select -
$100,000
$250,000
$500,000
$1,000,000
$2,000,000
Bodily Injury Per Accident
- Select -
$100,000
$250,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
Property Damage Per Accident
- Select -
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$500,000
$1,000,000
Combined Single Limit
- Select -
$250,000
$500,000
$750,000
$1,000,000
$2,000,000
Do you need Physical Damage coverage?
Yes
No
Vehicles To Be Covered
Vehicles
VIN
Year
Make
Model
Actions
Edit
Delete
There are no
Vehicles.
Add Vehicle
Maximum number of vehicles reached.
Are any vehicles Financed / Loss Payees?
*
Yes
No
Please indicate which vehicle(s) and give name and address of loss payees
Do you install GPS systems in vehicles?
*
Yes
No
Do you plan on installing GPS?
*
Yes
No
Do you have kill switched in vehicles?
*
Yes
No
Do you plan on installing kill switches?
*
Yes
No
What is the best time to contact you regarding your quote?
Morning
Afternoon
Evening
Anytime
Other
What time works best for you?
Would you like a quote from a specific agent?
Joe Coccimiglio
Heidi Coccimiglio
Scott Coccimiglio
Jeff Jaramillo
Eric Blumberg
How were you referred to us?
Additional Comments
Additional Documents
Drop files here or
Select files
Max. file size: 10 MB.
Consent
*
Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.
I Agree
All the above information is accurate and true to the best of my knowledge.
*
Yes
Email
This field is for validation purposes and should be left unchanged.
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