LENDER'S SINGLE INTEREST (LSI)
Application for Insurance
(Please print this application, fill it out, then mail or fax it using the information above)

     Collections Manager_________________ Phone (_____)_____________

LOAN UNDERWRITING

Downpayment: ___% new auto; ___% used auto. Maximum debt/income ratio ____%.

Do you use a credit scoring system? (   ) Yes (   ) No    If yes, what kind?_______________

Are dealers set up under full/partial recourse? (   ) Yes (   ) No   Repurchase? (   ) Yes (   ) No

INSURANCE INFORMATION

Do you verify insurance coverage before a loan is granted?    (   ) Yes (   ) No

Do you follow-up on the insurance status of each loan?    (   ) Yes (   ) No

If yes, do you use an automated tracking service? Name_______________________________

Do you intend to continue follow-up/tracking of insurance?    (   ) Yes (   ) No

Do you use LSI (or VSI/blanket) to protect you auto loans?    (   ) Yes (   ) No

Agency:_______________ Company:___________________ Policy Date:____/____/____

Premium per: $_____auto direct  $_____indirect  $_____RV  $_____boat  $_____mobile home

Deductible: $_________ Limits $_________ Are skip losses covered? (   ) Yes (   ) No

Cancelled/non-renewed:_____/_____/_____. Will coverage continue on portfolio? (   ) Yes (   ) No

Signing this application does not bind the applicant nor the Company/Underwriters to complete this insurance.
All of the information provided is accurate to the best of my knowledge and I understand that the policy,
if issued, will be based upon the information provided herein.

_________________________________ ___________ __________________________ _________________
                 authorized signature                         date                    printed name                                   title