/ STATE OF MINNESOTA
DEPARTMENT OF COMMERCE
85 – 7th Place East
St. Paul, Minnesota 55101
(651) 539-1599 / AUTO RENTAL COMPANY
SALES OF INSURANCE
Filing pursuant to Minnesota Statutes §72A.125

INSTRUCTIONS

This form must be filed by the Auto Rental Company and signed by the Auto Rental Company owner or executive officer. Submit the completed form and attachmentsvia e-mail to with "AUTO RENTAL COMPANY FILING" in the subject field.

Auto Rental Company Name / FEIN
Business Address
City / State / Zip Code / Foreign Country
Phone Number (include extension)
( ) / E-mail Address For Business Use
Mailing Address
City / State / Zip Code / Foreign Country

AGREEMENT AND CERTIFICATION

By filing this form, the undersigned owner/officer and the Auto Rental Company listed above (the “Company”) agree and certify as follows:

  1. The Company intends to offer or sell “rental vehicle personal accident insurance,” “personal effects insurance,” or “liability insurance” in Minnesota in conjunction with the rental of a vehicle, pursuant to Minnesota Statutes §72A.125.
  1. The insurance to be sold by the Company will be limited in availability to rental vehicle customers (though coverage may extend to the customer, other drivers, and passengers using or riding in the rented vehicles), and limited in duration to a period equal to and concurrent with that of the vehicle rental.
  1. The forms and rates for the insurance to be sold by the Company have met the requirements of Minnesota Statutes §61A.02, §62A.02, or other relevant statutory sections requiring approval of forms and rates, taking into account the possible infrequency and severity of loss that may be incurred.
  1. The persons who will be engaged in the sale of these insurance products are employees of the Company who do not receive commissions or other remuneration for selling the products in addition to their regular compensation, and the compensation of these Company employees is not determined in any part by the sale of insurance products.
  1. The Company has developed and will conduct a substantive and regular training program for its employees, and the Company has attached a copy of its training program to this filing.
  1. The Company assumes all responsibility for the authorized actions of all unlicensed Company employees who sell insurance products on its behalf.
  1. The Company, with respect to itself and its employees, will be subject to Minnesota Statutes Chapter 72A regarding the marketing of insurance products and the conduct of those persons involved in the sale of insurance products in the same manner as if it were a licensed insurance producer.
  1. CONSENT TO SERVICE OF PROCESS. KNOW ALL BY THESE PRESENTS: That in compliance with the Laws of the State of Minnesota, the above-named company does hereby appoint the Commissioner of Commerce of the State of Minnesota and her/his successors in such office, as its true and lawful attorney upon whom may be served all legal process in any action or proceeding in which it may be a party and which relates to or involves any transaction covered by the Insurance Laws of the State of Minnesota, and does hereby expressly consent and agree that service upon such attorney shall be as valid and binding as if due and personal service had been made upon it and that such appointment shall be irrevocable.

Signature of Auto Rental Company Owner or Executive Officer / Date
Name(please print) of Auto Rental Company Owner or Executive Officer / Title