 983 Old Eagle School, Suite 616 Wayne, PA 19087 PHONE: 800-446-5950 FAX: 610-254-9893 RESIDUAL VALUE INSURANCE
APPLICATION I. GENERAL APPLICANT INFORMATION Applicant: _________________________________________________ Address: _________________________________________________ City, State Zip: _____________________________________________ Contact: _____________________ Title: ________________________ Phone: ( ) FAX: ( )
(Please answer the following questions as completely as possible. Provide attachments if necessary.) II. LEASE / BALLOON LOAN PORTFOLIO CHARACTERISTICS A. Number of Lease/Loan Originations for Most Recently Completed Year: _____ B. Number of Lease/Loan Originations Projected for Coming Year: ___________ C. Average MSRP: New ________________ Used ________________________ D. Residual Setting: Average Residual Amount ___________________________ - How are Residuals Established: ALG _____ Black Book ______ Other _______ - Are Residuals Enhanced? If Yes, Describe At What Level: _________________ __________________________________________________________________ -
Are Vehicle Enhancements Chosen On A Target Basis? Please Describe -
Is Factory Invoice Used to Establish Residual? Yes _____ If No, Describe/Define E. Lease/Loan Terms: Average Term ____________________________________ - Term Breakdown (Percentage of Portfolio)
F. Mileage Allowances: Annl Standard _______ Annl. Low _______ Annl. High ______ - Percentage of Portfolio at Standard, Low and High: ___________________________ - Excess Mileage Penalty: ________________________________________________ - Is Mileage Allowance
Increased for Odd Terms?: _______ If Yes, Please Explain: G. Vehicle Make
and Model Concentrations: - List All Makes that Comprise More than 15% of the Portfolio: ___________________ _______________________________________________________________________ - List any Model that Comprises More than 10% of the Portfolio: __________________ H. Describe the Credit Quality of the Applicants Lessees/Borrowers: ______________ _______________________________________________________________________ III. HISTORICAL PERFORMANCE A. Please Complete
the Grid Below:
B. Describe Remarketing
and Vehicle Disposition Strategy and Process ____________ - At What Point
During Lease/Loan Does Telemarketing/Remarketing Begin: _________ - Disposal Methods (Yes/No & %): Auction _______ Wholesale _______ Retail ______ - Is Wholesale
Guidebook (Black Book, Kelly, NADA etc.) Used for Reference When IV. COVERAGE PARAMETERS A. Please Describe
Request for Coverage: _____________________________________ B. Desired Level
of Coverage?: - If Other Than
Contract Residual, Please Explain: _______________________________ V. ATTACHMENTS Please Provide the
Following Attachments: 2. Copy of Applicant's Current or Most Recent Residual Value Policy, 3. Copy of Applicant's Lease Agreement and/or Balloon Note Contract. FRAUD WARNING "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, AND UT; IN MAINE AND VIRGINIA, INSURANCE BENEFITS MAY ALSO BE DENIED.)" NOTICE TO COLORADO APPLICANTS: "IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES." NOTICE TO OHIO APPLICANTS: "ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD." NOTICE TO OKLAHOMA APPLICANTS: "WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY." NOTICE OF INSURANCE INFORMATION PRACTICES: PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US. I hereby declare that the above statements are true to the best of my knowledge. Signing of this Application does not bind the undersigned to purchase any insurance, nor does it in any way signify any acceptance of any coverage on the part of the Company. The Applicant is hereby applying to the Company for a policy of insurance as set forth in this questionnaire on the basis of the statements contained herein. _______________________________________________
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