7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?
* MARITAL STATUS / CIVIL UNION (if applicable)
EFFECTIVE DATE NAMED INSURED(S)POLICY NUMBER
NAIC CODE
CARRIER
AGENCY
AGENCY CUSTOMER ID:
The ACORD name and logo are registered marks of ACORD
NAME OF OTHER OWNERVEH #NAME OF OTHER OWNERVEH #
WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY AND
REGISTERED TO THE APPLICANT?
1.
Y / N
EXPLAIN ALL "YES" RESPONSES
GENERAL INFORMATION
2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS? (no explanation needed)
3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?
4. ARE ANY VEHICLES LEASED TO OTHERS?
VEH #VEH #
$
COSTDESCRIPTION
$
COSTDESCRIPTION
5. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups)
6. ARE ICC (Interstate Commerce Commission), PUC (Public Utility Commission) OR OTHER FILINGS REQUIRED? (If "YES", attach ACORD 194) (no explanation needed)
© 1993-2015 ACORD CORPORATION. All rights reserved.Attach to ACORD 125ACORD 127 (2015/12)
COVERAGES / LIMITS
USE ACORD 137 FOR YOUR STATE TO PROVIDE COVERAGES / LIMITS INFORMATION
ACORD 163 attached for additional driversDRIVER INFORMATION
CITY, STATE AND ZIP CODE
DOC
USE
%
VEH #
USE
HIRE
DATE
LIC
STATE
SOCIAL SECURITY NUMBER
DRIVERS LICENSE NUMBER/
LIC
YEAR
EXP
YRS
DATE OF BIRTH
STAT
* MAR
SEX
NAME
#
DRIVER
LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS.
BROADEN
NO-FAULT
BUSINESS AUTO SECTION
DATE (MM/DD/YYYY)
DESCRIPTION OF GARAGE / STORAGE LOCATIONS
$
MAXIMUM DOLLAR VALUE SUBJECT TO LOSS
Describe:
LOCATION TRACKINGMILEAGE TRACKINGMONITOR VEHICLE MAINTENANCETRACK FUEL CONSUMPTION
NAVIGATION
MONITOR DRIVER SAFETY
Please indicate how you utilize the devices (check all that apply):
%
If "YES", what percentage of vehicles in your overall fleet are monitored (1 - 100%)
17. DO YOU HAVE ELECTRONIC MONITORING DEVICES THAT RECORD AND TRANSMIT DATA IN ANY OF YOUR VEHICLES?
Page 2 of 4
16. ARE ALL VEHICLES TO BE INCLUDED IN THIS POLICY PART OF A FLEET?
13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION?
12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION?
11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD?
10. DOES THE APPLICANT OBTAIN MVR (Motor Vehicle Record) VERIFICATIONS?
9. ANY VEHICLES USED BY FAMILY MEMBERS? IF SO, IDENTIFY.
8. ANY HOLD HARMLESS AGREEMENTS?
15. HAS AGENT INSPECTED VEHICLES?
# YRS REVPLACE (CITY, STATE)TYPEDATE (MM/DD/YYYY)DRV #
1. A speeding violation of up to six (6) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, or
2. A speeding violation of up to ten (10) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 55 mph through 75 mph.
APPLICABLE ONLY IN KANSAS: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO INSURERS:
14. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?
Y / N
EXPLAIN ALL "YES" RESPONSES
GENERAL INFORMATION (continued)
AGENCY CUSTOMER ID:
CERTIFICATE
AS LESSOR
INSURED
EVIDENCE:RANK:NAME AND ADDRESS
REGISTRANT
OWNER
INTEREST
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
LIENHOLDER
EMPLOYEE
VEHICLE: LOCATION:
REFERENCE / LOAN #:
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names
CERTIFICATE
AS LESSOR
INSURED
EVIDENCE:RANK:NAME AND ADDRESS
REGISTRANT
OWNER
INTEREST
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
LIENHOLDER
EMPLOYEE
VEHICLE: LOCATION:
REFERENCE / LOAN #:
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ACORD 127 (2015/12)
LENDER'S LOSS
PAYABLE
LENDER'S LOSS
PAYABLE
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ACORD 129 attached for additional vehicles
Page 3 of 4
AGENCY CUSTOMER ID:
$
COST NEW
SYM
COLL
OTC SYM
COMP /
$TOTAL PREM:
OTC
FG
REIMB
RENT
COLL
COMP/
LSP
FTW
FT
F
C OF L
SPEC
& LABOR
TOWING
MOTOR
UNDRINS
MOTOR
UNINS
MED PAY
FAULT
ADD'L NO-
FAULT
NO-
LIAB
COVERAGES
CHECK
FOR HIRE
SERVICE
RETAIL
COMM'L
FARM
PLEASURE
USE
15 MILES +< 15 MILES
WORK / SCHOOL
DRIVE TO
ZIPSTATECOUNTYCITYSTREET (Required in KY)
GARAGING
ADDRESS
STATE
LIC
TERR GVW / GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERMINAL
NET VEH
DR/CR:
OTC
COLL$
$
C OF L
SPEC
COMP/
$
ST AMTAA
ACV
DEDUCTIBLES
SYM / AGE
V.I.N.:
TYPE:
BODY
MODEL:
MAKE:
YEARVEH #
PP SPEC COML
VEHICLE TYPE
$
COST NEW
SYM
COLL
OTC SYM
COMP /
$TOTAL PREM:
OTC
FG
REIMB
RENT
COLL
COMP/
LSP
FTW
FT
F
C OF L
SPEC
& LABOR
TOWING
MOTOR
UNDRINS
MOTOR
UNINS
MED PAY
FAULT
ADD'L NO-
FAULT
NO-
LIAB
COVERAGES
CHECK
FOR HIRE
SERVICE
RETAIL
COMM'L
FARM
PLEASURE
USE
15 MILES +< 15 MILES
WORK / SCHOOL
DRIVE TO
ZIPSTATECOUNTYCITYSTREET (Required in KY)
GARAGING
ADDRESS
STATE
LIC
TERR GVW / GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERMINAL
NET VEH
DR/CR:
OTC
COLL$
$
C OF L
SPEC
COMP/
$
ST AMTAA
ACV
DEDUCTIBLES
SYM / AGE
V.I.N.:
TYPE:
BODY
MODEL:
MAKE:
YEARVEH #
PP SPEC COML
VEHICLE TYPE
$
COST NEW
SYM
COLL
OTC SYM
COMP /
$TOTAL PREM:
OTC
FG
REIMB
RENT
COLL
COMP/
LSP
FTW
FT
F
C OF L
SPEC
& LABOR
TOWING
MOTOR
UNDRINS
MOTOR
UNINS
MED PAY
FAULT
ADD'L NO-
FAULT
NO-
LIAB
COVERAGES
CHECK
FOR HIRE
SERVICE
RETAIL
COMM'L
FARM
PLEASURE
USE
15 MILES +< 15 MILES
WORK / SCHOOL
DRIVE TO
ZIPSTATECOUNTYCITYSTREET (Required in KY)
GARAGING
ADDRESS
STATE
LIC
TERR GVW / GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERMINAL
NET VEH
DR/CR:
OTC
COLL$
$
C OF L
SPEC
COMP/
$
ST AMTAA
ACV
DEDUCTIBLES
SYM / AGE
V.I.N.:
TYPE:
BODY
MODEL:
MAKE:
YEARVEH #
PP SPEC COML
VEHICLE TYPE
$
COST NEW
SYM
COLL
OTC SYM
COMP /
$TOTAL PREM:
OTC
FG
REIMB
RENT
COLL
COMP/
LSP
FTW
FT
F
C OF L
SPEC
& LABOR
TOWING
MOTOR
UNDRINS
MOTOR
UNINS
MED PAY
FAULT
ADD'L NO-
FAULT
NO-
LIAB
COVERAGES
CHECK
FOR HIRE
SERVICE
RETAIL
COMM'L
FARM
PLEASURE
USE
15 MILES +< 15 MILES
WORK / SCHOOL
DRIVE TO
ZIPSTATECOUNTYCITYSTREET (Required in KY)
GARAGING
ADDRESS
STATE
LIC
TERR GVW / GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERMINAL
NET VEH
DR/CR:
OTC
COLL$
$
C OF L
SPEC
COMP/
$
ST AMTAA
ACV
DEDUCTIBLES
SYM / AGE
V.I.N.:
TYPE:
BODY
MODEL:
MAKE:
YEARVEH #
PP SPEC COML
VEHICLE TYPE
VEHICLE DESCRIPTION
ACORD 127 (2015/12)
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
Page 4 of 4
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
SIGNATURE
AGENCY CUSTOMER ID:
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in PR
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a
felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus
established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to
any material fact may be violating state law.
Applicable in ME, TN, VA and WA
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties
(may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in KY, NY, OH and PA
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim
for each such violation)*. *Applies in NY Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by
an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of
an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in FL and OK
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in CO
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to
defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
ACORD 127 (2015/12)
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