Form 593741 - Wells Fargo Cdf Inventory Insurance Program Enrollment Form For Outdoor Products Group

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C L E A R
ADMINISTERED BY:
WELLS FARGO CDF INVENTORY INSURANCE PROGRAM
SAFEHOLD SPECIAL RISK INC
ENROLLMENT FORM*
ST
190 RIVER RD. 1
FLOOR
SUMMIT, NJ 07901
TEL: 844-584-0539
For OUTDOOR PRODUCTS GROUP
FAX: 866-397-8534
EMAIL:
PLEASE PRINT OR TYPE
DEALER NAME
DBA
YES, PLEASE INSURE ALL MY DEALER NUMBERS THROUGH THE CDF INVENTORY INSURANCE PROGRAM
NO, PLEASE INSURE ONLY THE DEALER NUMBERS FOR WHICH I HAVE SUBMITTED AN APPLICATION
MAILING ADDRESS
CITY
STATE
ZIP CODE
PRIMARY LOCATION ADDRESS
CITY
COUNTY
STATE
ZIP CODE
PHONE NUMBER
FAX NUMBER
EMAIL
CONTACT PERSON
EFFECTIVE DATE OF COVERAGE
TYPE OF INVENTORY FINANCED WITH CDF
CDF REPRESENTATIVE
CONTACT PERSON
PHONE NUMBER
EMAIL
INFORMATION
COMPLETE ADDRESS OF EACH LOCATION TO BE INSURED
LOC.
DEALER NO.
ADDRESS
CITY
COUNTY
STATE
ZIP CODE
1
2
3
Use a separate sheet if more than three locations
RATES BASED UPON PRODUCT CODE ASSIGNED BY CDF (DETERMINED BY HIGHEST PERCENTAGE)
This is an industry-specific table. Rates will vary by industry. Please visit for various rates.
States:
AL, FL, GA, KS, LA, MS, NC, OK,
Coverage
States:
States:
Deductible †
SC & TX
AK, AR, CA, IL, MO, OR, TN, & WA
All Other
(Check One)
$1,000
$1.59/$1,000
$1.47/$1,000
$1.20/$1,000
$2,500
$1.35/$1,000
$1.25/$1,000
$1.02/$1,000
$5,000
$1.24/$1,000
$1.15/$1,000
$0.94/$1,000
$10,000
$1.19/$1,000
$1.10/$1,000
$0.90/$1,000
The rate is applied per $1,000 of the average daily balance billed and reported monthly by CDF.
All rates shown include applicable surplus lines insurance taxes and fees.
† Additional deductibles apply as follows: Hail, 5% of unit value - $50,000 max/occurrence; Flood, 5% of unit value $50,000
max/occurrence; Earthquake, 10% of unit value - $100,000 max/occurrence; Wind, deductibles vary by location. Please contact
Safehold Special Risk, Inc for details regarding coverage. *Approval of this enrollment request is subject to underwriting approval.
This is a request for inventory insurance for inventory financed by Wells Fargo Commercial Distribution Finance (CDF) covering the original
invoiced amount financed by CDF. This insurance does not cover inventory financed through other sources. It is agreed that the information
contained herein has been prepared from your records and is true and correct.
APPLICANT’S SIGNATURE
DATE
X
Loss History Last 5 Years:
Check if none $
Total Losses
Number of Claims, or Attach Loss Summary for Details
Wells Fargo CDF’s premium billing and collecting services under the program are provided as an accommodation to CDF dealers and a service to
the program administrator, Safehold Special Risk, Inc. In consideration of such services, CDF may collect a fee for its administrative services from
the program administrator. Participation under this program is at the discretion of the dealer. Dealers may obtain insurance coverage elsewhere
to satisfy their obligations under loan agreements with CDF. Wells Fargo CDF is not promoting, marketing or otherwise representing Safehold
Special Risk, Inc. or the insurance carrier for the program to CDF dealers. Wells Fargo CDF is not soliciting or negotiating insurance on behalf of
dealers, Safehold Special Risk, Inc. or any third party.
Underwritten by AIX Specialty Insurance Company – Non Admitted – Best Rating “A-XIV”
Program Administered by Safehold Special Risk, Inc., Summit, New Jersey, a non-bank subsidiary of Wells Fargo & Co.
SSR_CDF OutdoorProductsGroup App 09 16
593741 (Rev 02 – 12/16)
Page 1 of 1

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