/ Agency:
Producer:
Address:
City,St,Zip
Email:
Send Submissions to: / Phone:
Ph: 912.450.7500 W: 888.554.8864 Fx: 912.450.7707 / Date:

Repossession Supplemental Application

Applicant: / Effective Date:
Address: / Years in Bus:
StreetCityCountyStateZip / Owners Name:
Location if different: / Phone:
Individual Corporation LLC / Need Filings: Yes No
Partnership Joint Venture Other(describe) / If Yes, Docket/MC #

Primary Customers for Repossession WorkList name of Each

Bank / Yes No
Auto Credit Co / Yes No
Auto Dealer / Yes No
Pawn / Yes No
Other / Yes No

Describe Repossession operations in detail

Are owners notified prior to repossession? / Yes No / Describe:
Are keys sent to you by the lien-holder? / Yes No / If not, are vehicles ever hotwired? Yes No
Do you use temporary employees to repossess Vehicles? / Yes No / If yes, how often?
If temporary employees used describe hiring requirements:
Do you use subcontractors? / Yes No / If yes is there a written contract? / Yes No
If subcontractors are used how is their insurance verified?
Is workers comp carried on all employees? Yes No
Does the applicant or employees carry firearms? Yes No
During the repossession, in the event of a confrontation, how do you handle?
Has the applicant ever been bonded? Yes No / Has the applicant ever been denied a bond? Yes No
Has the applicant ever been arrested? Yes No / Has the applicant ever been convicted of a crime? Yes No
What is the procedure for training new employees?
What percent of the repos are done by you and your employees? / Driven / Towed
What percent of the repos are done by other than you and your employees? / Driven / Towed
Total must equal 100% / Driven / Towed
Estimated total annual number of repossessions? / Driven / Towed

Estimated annual receipts

Towing Service / Repo Towed / Repo Drive-away / Total Receipts
Number of Adjusters (collectors) / Total Annual Payroll all Adjusters
What types of vehicles/equipment are repossessed
Private Passenger Autos / % / Light Commercial Trucks / %
Heavy Commercial Trucks / % / Commercial Trailers / %
Recreational Vehicles / % / Other(describe) / %
Any storage of repo vehicles/equipment? / Yes No / If yes, what are annual receipts?
If any storage describe lot and protection:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material therto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] penalties. (not applicable in CO, HI, NE, OH, OK, OR; in ME and VA, insurance benefits may also be denied)

Applicants SignatureDate

TUMI RP1 6-10