AUTOMOBILE LONG TERM CONTINGENT INSURANCE APPLICATION
(Please print this application, fill it out, then mail or fax it using the information above)

1. Do you currently have Lessor's Contingent coverage?
    If yes, please provide the name of your current insurance company and
    expiration date.____________________________________________________________________

2. Have there been any insured or uninsured contingent losses?
    Please give details; i.e. claim against the lessor because the lessee had no
    insurance coverage or inadequate coverage at the time of loss. Attach separate sheet if necessary.     _________________________________________________________________________________

3. What is the term of lease? Minimum____________months/Maximum____________months.
    Please attach a sample of entire lease agreement.

4. Do you understand that vehicles leased for less than one year are not covered by Lessors
    Contingent Liability?___________________________________________

5. Do you require lessee's insurer to give notice of cancellation or non-renewal?______
    How many days?_________

6. Do you understand that your lease agreement must require the lessee to provide a policy
    with limits of liability of not less than $100,000 per person and $300,000 per occurrence
    Bodily Injury and $50,000 per occurrence Property Damage and include your interest as
    an insured?______________________

7. Is it your policy to promptly repossess a vehicle if the lessee fails to provide you with
    the insurance required by the lease agreement? Please explain.________________________
    _____________________________________________________________________________

8. Do you understand that it is your responsibility to maintain in your file a certificate of
    insurance from the lessee's insurer?________________________________________________

9. Do you deliver vehicles for lease prior to receipt of the certificate of insurance? If so,
    lease explain the follow-up procedure._______________________________________________

10. Do you understand you must track lessee coverage during the term of the lease or
     begin repossession proceedings if the lessee’s insurance is cancelled, non-renewed,
     expired, or does not meet the insurance required by the lease agreement? If not, please      explain._______________________________________________________________________
               

11. Do you use the services of an independent insurance tracker?
      If so, which company?_____________________________________________

12. Are leases generated in dealerships?_______________ If yes, is it your procedure
      to re-confirm the lessee’s insurance prior to funding?________________________________

13. What percent of your leases are:   personal leases:_________% corporate leases:_________%

14. How many lease customers represent the total lease portfolio?___________________________

15. How many do you anticipate over the next 12 months: new leases: ____ lease terminations:____

16. What % of your lessees are rated:
      ____% A credit   ____% B credit  ____% C credit   ____% D credit

17. Please indicate the actual number (and circle type, if applicable) of the following leases are in
      your in your portfolio:

a. Public or private livery
    (i.e. taxi, bus, limo service, elderly transportation)____________________________
    (i) Total Number of 12-15 passenger vans __________________________________

b. Motorcycles, driver training school vehicles, race cars_________________________

c. Professional or volunteer ambulances,
    emergency vehicles, police vehicles________________________________________

d. Trucks in excess of 12,500 lbs. GVW or Trucker units_________________________

e. Autos leased for the purpose of rent, re-lease, or sub-lease______________________

f. Lessees that self-insure their primary liability
   and/or physical damage___________________________________________________

18. Please indicate the number of vehicles in each category:

Broker of Record Authorization -- Please recognize Tri-Arc Financial Services, Inc.
as the broker of record for our company for the purposes of quoting Lessors
Contingent Insurance. The signing of this application does not bind the applicant
or the Insurance Company to the insurance. It is agreed that the information contained
herein shall be the basis of the contract should one be issued.

Producer______________________________ ____________________________________
                                                                                  (Name of Leasing Entity )

Agency_______________________________ By:__________________________________
                                                                                    (Signature Required)

Address_______________________________ _____________________________________
                                                                                              (Address)

_____________________________________ ______________________________________

Phone (_______)________________________ Phone (______)________________________

Fax (_______)________________________ Fax (_______)___________________________

E-Mail______________________________ E-Mail__________________________________

Date__________________________________ Contact Person________________________

 

COMPLETE THIS FORM ONLY IF COVERAGE IS NEEDED FOR TRUCKS
OVER 12,500 LBS. GROSS VEHICLE WEIGHT

1) Describe the specific criteria used to qualify new lessees. Include detail on your requirements
    regarding financial strength, type of business and driver standards.

2) What circumstances would cause you to be unwilling to lease a truck to a customer?

3) Please comment on why you believe a prospective lessee would choose your company as
    their truck/trailer leasing source.

4) Please provide the actual number (#) of units in each weight category and radius groups:

5) Please provide detailed description of use (as to facilitate same, you may provide a
    customer list with the goods hauled/service provided and the number of trucks/trailers
    leased per customer).

6) What are the minimum limits of liability required from all truck/trailer lessees?

7) In addition to your leasing operation do you also rent vehicles? If yes, please indicate
    the insurance carrier and the effective date of coverage for your rental operations.

This application is understood to be an inducement to the issuance of a policy
of insurance by company and applicant warrants that all answers to questions
are true and correct to the best of applicant’s knowledge and belief.

Leasing Company: _______________________________________________________

Insured’s Signature: ____________________________________ Date: ____________

CONTINGENT APPLICATION - LIVERY ADDENDUM

1. Total number of “livery” units in portfolio (a vehicle used to transport people whether
    for hire or not, i.e. limousines, van pool, airport shuttle, etc.).

2. Total number of 12 - 15 passenger vans:

3. Please provide number of livery units by state of garaging (i.e. # in NJ, # in PA, # in CA).

4. Do any of the livery units represent school vans or school buses used to transport children?
    If so, please provide details (how many, what size, etc.).

5. Please provide information regarding the radius of travel on the livery units.

6. What limit of liability do you require the lessee to provide on the livery units?

7. How many lessees represent the total number of livery leases?

8. Please provide detailed description of use on the livery units.

This application is understood to be an inducement to the issuance of a policy
of insurance by the company and applicant warrants that all answers to
questions are true and correct to the best of applicant’s knowledge and belief.

Leasing Company: _______________________________________________________

Insured’s Signature: ____________________________________ Date: ____________