Dealership Information Business Legal Name * DBA Name (if different) Address Line 1 * Address Line 2 (optional) City * State * Select State ALAKAZAR CACOCTDE FLGAHIID ILINIAKS KYLAMEMD MAMIMNMS MOMTNENV NHNJNMNY NCNDOHOK ORPARISC SDTNTXUT VTVAWAWV WIWY Zip Code * Corporate Structure * Select one Sole Proprietorship LLC Corporation (Inc) Partnership Type of Business * (check all that apply): New Cars Used Cars BHPH Powersports RV Marine Agency Website Tax ID Type *: EIN SSN EIN Number * Staffing & Contact Information Please provide the primary contact and any additional contacts for the dealership. Primary Contact (Dealer Principal) Name * Phone * Email * General Onboarding Email * Additional Contact Name Title/Role Select title General Manager Office/Accounts Payable Finance Director Service Manager Parts Manager Detail Manager Other Phone Email × + Add Another Contact Operations & Systems In-House Service Department? * Yes No Current Labor Rate (per hour) Sales Tax – Parts (%) Sales Tax – Labor (%) Labor Time Guide Parts Used Select parts type OEM Only Aftermarket Only Both OEM & Aftermarket Units Sold per Month: New Certified Used Number of F&I Producers Number of Sales People DMS Provider Menu Provider Send Chemicals To All Other Supplies To Dates & Reinsurance Requested Effective Date * Training/Launch Date Reinsurance/Retro Structure * Select one Reinsured (Own reinsurance) Retro (Retro program) Direct (no participation) Not Sure Reinsurance Manager Name Reinsurance Manager Phone Reinsurance Manager Email Agency Information Agency Name Agent/Rep Name Agent/Rep Phone Agent/Rep Email Notes & Special Instructions Banking Information Bank Name * Account Holder Name * Routing Number * Account Number * Bank City Bank State Select State ALAKAZAR CACOCTDE FLGAHIID ILINIAKS KYLAMEMD MAMIMNMS MOMTNENV NHNJNMNY NCNDOHOK ORPARISC SDTNTXUT VTVAWAWV WIWY Attach a voided check or deposit slip separately (if requested) for verification. Uploads & Consent W-9 Upload (optional) If not uploaded, a W-9 will be generated from your information. I am authorized to submit this application and consent to Top Shelf Protection using the information provided to set up the dealership (including ACH) and to generate a W-9 if needed. I understand that submission does not guarantee acceptance. We collect EIN/SSN and bank routing/account numbers solely for ACH setup. Full numbers are never displayed or emailed—only the last 4 digits are used in confirmations. Your uploaded files are handled confidentially. Submit Application Success! Your dealer signup application has been submitted.
