Dealer Application

Dealer Application for E-Bike Battery Warranties

Business Information

Business Name *

Business Addres *

City *

State/Prov. *

Zip Code *

Phone *

Email *

Password *

Confirm Password *

Website URL *

Year Established *

Tax ID (EIN) *

Ownership Structure (Sole Proprietor, LLC, Corporation, etc.)

Primary Contact Name *

Primary Contact Title: *

Email Address*

Phone Number *

Number of Locations *

Do you currently sell extended warranties *

If yes, which brands

Approximate Monthly E-Bike Sales Volume*

Brands of E-Bikes Sold *

Do you offer in-house repairs or maintenance services *

How do you promote warranties to your customers? *

Would you need training or marketing materials for selling our warranties? *

Bank Name: *

Account Number: *

Routing Number:*