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RLP / SLI Online Application Form
*All fields are required

1.Business name(s) of applicant:
(list full entity name, dba's, etc., and
state of incorporation, if applicable)
2.FEIN #:
3.Names and Titles of all owners,
partners, and managers:
4.Telephone number of applicant: - -
Name of person to contact regarding
insurance matters:
5.Address of main business location:
(including zip code)
6.Mailing address of applicant:
7.Email address of applicant:
8.Name of current insurance carrier:
Policy period dates:
From:
 mm    dd    yyyy
To:
 mm    dd    yyyy
9.Is the policy described in item #8 being cancelled, non-renewed or neither?:
NOT APPLICABLE IN MISSOURI		 Cancelled
Non-renewed
Neither
10.Current / renewal premium rate?:
11. Describe current fleet insurance coverage:
Owners Liability Limit
Customer's Liability Limit
Fire, Theft, CAC (or Comprehensive) Deduction
Collision Deductible
12. Does the applicant have any experience
in the short-term rental business?:		 Yes    No
(a) If yes, describe, including number of
years owning this or other rental business:
(b) If no, describe other business experience:
13.Describe all OTHER business(es)
(ie., OTHER than the one described in this application):
14.(a) Total number of vehicles for rent:
Private Passenger #:
Trucks & Vans #:
Other #:
Total:
(b) Does applicant request our company
to insure all vehicles held available
for rent by applicant?:		 Yes    No
if no, explain why and enter total number
of vehicles to be insured:
(c) Does applicant rent vehicles with the
"option to buy" or "rent to own"?:		 Yes    No
(d) Does applicant hold any vehicle(s) that:
     (l) has more than one rear axle?: Yes    No
     (ii) is designed to haul other vehicles
     (like tractors or tow-trucks):		 Yes    No
     (iii) is designed to transport more than
     15 people:		 Yes    No
     (iv) has a gross vehicle weight of
     20,000 pounds or more?:		 Yes    No
15.Describe the rental practices followed by
the applicant, including specific reference
to age restrictions, cash rentals, local
customer rentals, military personnel, and additional drivers:
16.Does the applicant review the driving record
of employees before they are hired?:		 Yes    No
17.Describe vehicle maintenance procedures followed by the applicant:
18.Describe percentage of rental customers:
(please total 100%)
Airport / Tourist Traffic %:
Business / Corporate %:
Personal / Pleasure %:
Local Traffic %:
Insurance Replacement %:
Other %:
19.Provide the total average of vehicles available for rent during each of the last 3 years:
2003:
2004:
2005:
20.Provide the total number of accidents during each of the last 3 years:
2003:
2004:
2005:
21.Provide a detailed description of each
accident which caused, in total, bodily injury
or property damage in excess of $15,000:
22. Please include each of the following:
Click "Browse" to select a file to upload
(we accept word, pdf and excel files)
(a) Copy of present liability policy, if any
(b) Description of losses (past 3 years) - include company issued loss report
(if not available, please ask your agent)
(c) Schedule of vehicles - include years, makes, models
(d) Sample rental contract / agreement -
must be original
(e) Copy of all telephone directory advertising
22.Have you applied to your state's department
of insurance to obtain a limited license?:
(if you have a license, you may browse to upload copy)		 Yes, my license#: 

Yes, but my application is pending
No, not yet but I plan to do it once
        I am approved for SLI/RLP
Please describe the current computer system you operate
Do you have internet access?: Yes    No
How do you connect to the internet?: Modem
Cable Modem
DSL
T1
Other
Do the customer workstations have
internet access?:		 Yes    No
What operating system do your computers
run on?:		 Mac
Win 95
Win 98
Win 2000
Win XP
DOS
Other
Which Rental System do you use?: TSD (Rent 200)
Bluebird
Other   
Applicant Warranties

Applicant warrants that all the information on this application is true, correct, and complete. Applicant understands that it is their responsibility to read and comprehend the contents of this application, and that any material misrepresentations or omission will invalidate coverage; and, note that this is not a policy of insurance, and that, regardless of the form's content, this document imparts no coverage whatsoever:
Notice to Applicants by State - Click here to view

 I understand the contents of this application and I declare that the information I provided         is true, correct, and complete.
  

NOTICE TO ALASKA APPLICANTS: A person who knowingly and with the intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information is guilty of a felony.

NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

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 policyholder 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 DELAWARE APPLICANTS: Any person who knowingly, and with the intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, any insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly, and with the intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punish able by fines, imprisonment or both.

NOTICE TO IDAHO APPLICANTS: Any person who knowingly, and with the intent to defraud or deceive any false, incomplete or misleading information is guilty of a felony.

NOTICE TO INDIANA RESIDENTS: A person who knowingly and with the intent to defraud an insurer files a statement of claims containing any false, incomplete or misleading information commits a felony.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the intent to defraud an insurance company or other person files an application for insurance or statement of claim 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.

NOTICE TO LOUISIANA MAINE AND TENNESSEE APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or another person, files a statement of claim contain 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, subject to criminal prosecution and civil penalties. Insurance benefits may also be denied.

NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEVADA APPLICANTS: Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

NOTICE TO NEW HAMPSHIRE APPLICANTS: Any person who, with the purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false , incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or any insurance company, commits a fraudulent insurance act, which is a crime, and subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

NOTICE TO OHIO APPLICANTS: Any person who, with the intent to defraud or knowing that he 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 the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of a n insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.

NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

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