Name:
Name of Business (including dab):
Description of Operation(s):
Business Location Address (Not Residential)
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Business Country Location
Business Phone
Cell Phone
Ownership (select one)
- Select One -
Individual
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LLC
Business Email
Are you a Licensed Ga Dealer?
Years Experience
Current / Prior Insurance Company Name
Have you had any insurance claims? Please provide loss runs
Have you ever attended a State Approved Used Car Pre License Seminar?
Would you like our agency to process your dealer application?
Please complete the following:
Owner(s)
I have provided the date of birth and state that the driver license is issued in for each individual?
Manager(s)
Sale(s)
Clerical
Mechanic(s)
Part Time Driver(s)
Household Resdents (non-employees)
Any owner or employees with violations or accidents in the past 3 years?
If yes, list person and details of violation and or accident:
Any owner or employees use company owned vehicles for personal use?
I have provided the date of birth and state that the driver license is issued in for each individual
Number of Dealer Tags
Radius of Operations
Do you own any towing devises or vehicles?
If yes, list with yr/make/model/vin:
Do you own, or are you a partner, shareholder, member or officer of any other business operation(s)?
If yes, please list business name and location:
Describe your theft barriers (fences&gate or post&cable):
What percentages by type do you sell or service?
Cars, sports utility, pickuyups, vans (private passenger type):
Motorhomes, travel/camp trailers:
Commercial trucks & trailers:
Construction or farming equipment:
Salvage parts:
% of Wholesale Operations
Coverages
IF NO LIMITS ARE SPECIFIED - MINIMUM LIMITS FOR YOUR STATE WILL BE PROVIDED
Garage Liability:
Uninsured Motorist:
Medical Payments:
Optional Physical Damage (coverage for Owned autos held for sale
Total Inventory amount:
Max value any one unit:
Deductible
Optional Garage Keepers (coverage for non-owned autos you repair)
Total Inventory amount:
Max value any one unit:
Deductible
Do you buy or sell vehicles outside of the State of Georgia?
If yes, which States?
Do you travel to these states in a company owned vehicle?
Do you drive a company vehicle outside the state of Ga?
How are your vehicles transported when purchased out of state?
Will you drive or store company owned vehicles at your personal residence?
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