08a --ust of all -------owners of dealership 1 auto dealer... · db.te ot appiication proposed...
TRANSCRIPT
DB.te ot Appiication Proposed Effective Date Business is Dea!er Group Street Address Post Office Box GENERAL INFORMATION
Majority Owner's Name
FRANCHISED NEW CAR/TRUCK/RV DEALER APPLICATION FOR INSURANCE
___________ Name of Dealership 08A -----------
App No .... _ of
-----------------------·······························-··-······ ---
Year Established ___________ City
City State _____ County _____ Z;p Code
··----------------------- Phone # -------------------- Majority Owners DOB�------Tax !O No. ________ Majority Owner Active 0 Yes D No Years of Experince Managing Dealerships Ust of all Owners of Dealership ""Use Separate Sheet if Necessary�---------��--�--------��------------·•-•+-··· ····------------········-� l····················-------------·······-�-?.r:Q�----------················------------------------------
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* !f app!ication is not attached please explain:Are there any Foreign Operations: D Yes O No !f Yes, explain:Ust and describe al! other Subsidiary Operations and Companies *Use Separate Sheet if Necessary
Details -------------------·
Dealership Contact Information
Genera! Managei Phone# Accounting Contact
Fax E-Mad
--------�----------------------------Phone# Fax Name of Person to receJve Correspondence from the Company Mailing Address Phone# PRODUCER INFORMATION
Producer Code Agency Name Street Address Email Post Office Box
_______ City Fax
____ State
Producer ------ -----------------
___________ Phone# ------------------------------------------------- C :ty ___________ State
City State
SASS FAD0001020-5 15
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-- Zip Code E--Mail
Fax County Zip Code Zip Code
Blue Oak Specialty Insurance Services, Inc.
*dba BOS Insurance ServicesPhone: 209 - 473 - 8938 Fax: 209 - 473 - 8939
Mailing address: PO Box 2048Orangevale, CA 95662-2048
