Dealership One Insurance Services

Dealership Insurance Services Application Form

Coverage is bound only when application is completely filled out and properly submitted to agency.
This binder application is NOT permitted for personal use. Use for authorize car retailers only.
You must print and complete the broker terms and agreement page for clients to sign and initial upon submitting the following form.

Dealer:

Address:

Email:

Vehicle Year:

Make:

Model/Body:

VIN#:

Driver Restrictions: Coverage is issued on a restrictive policy and applies only to drivers listed on the application. ALL OTHER DRIVERS EXCLUDED

#	Driver's Name Last, First, Initial	Driver's License#	Marital Status	Sex	Birth Date
1
2
3

Driver Information

Name:

Address:

City:

State:

Zip:

Home Phone:

Business Phone:

Credit Card #:

Expiration:

Card Brand:

Visa MasterCard AMEX Discover

Lien holder / Additional Insured

Name:

Address:

City:

State:

Zip:

Phone:

Confirmation Number:
Enter your Dealership Code followed by last 6 digits of VIN#

Dealership One Insurance Services

M.K.I.A. Inc.
740 Nordahl Road, Ste.120
San Marcos, CA 92069
LIC#0B45296

24 Hour Customer Service
Message Center
1-888-273-1293