Fillable Business Auto Application Phone # 888-495-4950 Fax # (Strickland Insurance Brokers)

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Business Auto Application Phone # 888-495-4950 Fax # (Strickland Insurance Brokers)

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Phone # 888-495-4950
Fax # 888-997-9970
P.O. Box 8010
Goldsboro, NC 27533-8010
Business Auto
Application
Policy Number:
Produce
r
Code
Phone:
Name:
A
ddress:
City:
State: Zip Code:
Insured:
DBA:
A
ddress:
City:
Zip Code:
State:
TYPE OF OWNERSHIP OF BUSINESS: (CHECK ONE)
PARTNERSHIP (MARRIED COUPLE)
INDIVIDUAL
Policy
CORPORATION
PARTNERSHIP (ALL OTHER)
To
Period From
QUESTIONS OR STATEMENTS
DESCRIBE BUSINESS OPERATIONS:
WHAT TYPES OF GOODS HAULED:
(1)
(2)
NO
YES
(3)
A
RE ANY VEHICLES USED TO TRANSPORT PEOPLE?
(4) WHAT IS THE RADIUS OF OPERATION?
(5) LIST LARGEST CITIES ENTERED IN EACH STATE
(6) DID ANY VEHICLE OPERATE OUTSIDE THE RADIUS WITHIN THE LAST 12 MONTHS?
IF YES, EXPLAIN
DOES USE OF VEHICLE(S) EXTEND BEYOND THE BORDER OF NORTH CAROLINA?
NO
YES
NO
YES
(7)
NO
(8)
A
RE THERE ANY STATE FILINGS REQUIRED?
IF YES, INDICATE STATES AND TYPE OF FILINGS NEEDED
DO YOU HOLD FEDERAL MOTOR CARRIER AUTHORITY?
IF YES, DOCKET# MC#
DO YOU REQUEST A FEDERAL FILING?
YES
NO
YES
(9)
NO
YES
(10)
NO
(11) IS ANY SPECIAL FILING REQUIRED SUCH AS OVERSIZED, OVERWEIGHT, CITY OR HAZARDOUS PERMIT?
IF YES, GIVE DETAILS
YES
TOTAL NUMBER OF VEHICLE(S) OWNED BY INSURED
(12)
NO
YES
A
RE ANY VEHICLE(S) LEASED TO OTHERS?
(13)
NO
A
RE ANY VEHICLES USED TO HAUL FOR OTHERS?
IF YES, PLEASE SPECIFY UNIT#
WITH THE EXCEPTION OF LIENHOLDERS, ARE ALL VEHICLES OWNED SOLELY BY AND REGISTERED TO THE APPLICANT?
IF NO, EXPLAIN
A
RE ANY VEHICLES CUSTOMIZED, ALTERED, OR HAVE SPECIAL EQUIPMENT?
IF YES, EXPLAIN OR ATTACH DESCRIPTION
WHAT IS THE ESTIMATED COST OF HIRE? (FOR HIRED AUTO COVERAGE)
(14)
YES
(15)
NO
YES
(16)
NO
YES
(17)
(18) WHAT IS THE TOTAL NUMBER OF EMPLOYEES? (FOR NONOWNED LIABILITY)
(19)
NUMBER OF TRANSPORT TAGS OR ANY UNASSIGNED LICENSE TAGS
COVERAGE LIMITS OF LIABILIT
Y
PREMIUM
LIABILITY
UTO MEDICAL PAYMENTS
UM / UIM
COMPREHENSIVE
COLLISION
HIRED AUTO
NONOWNED LIABILITY
GARAGEKEEPER LEGAL LIABILITY
SPECIFIED PERILS DEDUCTIBLE
COLLISION DEDUCTIBLE
TOTAL PREMIUM
A
CI-BA 04/05
Attach Plate Numbers
Policy Number:
BUSINESS AUTO SCHEDULE
LOADED
VEH# YEAR TRADE NAME-BODY VIN # SEATING CAPACITY
GVW
DEDUCTIBLES
STATED
VEH#
GARAGING LOCATION RADIUS
A
MOUNT
COMPREHENSIVE COLLISION
LOSS PAYEE
NAME, ADDRESS
VEH#
CITY, STATE, ZIP
DRIVER INFORMATION
NAME MVR
DRIVER DATE OF BIRTH DESCRIPTION OF VIOLATIONS VERIFIED
# DRIVER LICENSE NUMBER & STATE & ACCIDENTS (PAST 3 YEARS) YES/NO
NO
YES
NO
YES
NO
YES
PREVIOUS INSURANCE AND LOSS EXPERIENCE
NUMBER TOTAL TOTAL
POLICY
INSURANCE CARRIER POLICY # OF
A
MOUNT
A
MOUNT RESERVES RESERVES
PERIOD
A
CCIDENTS PAID BI PAID PD BI PD
FROM TO
FROM TO
FROM TO
FROM TO
APPLICANT PLEASE READ
I HEREBY DECLARE THAT ALL THE REPRESENTATIONS CONTAINED HEREIN ARE TRUE AND THAT THESE REPRESENTATIONS ARE
OFFERED AS AN INDUCEMENT TO THE COMPANY TO ISSUE THE POLICY FOR WHICH I AM APPLYING. I UNDERSTAND AND AGREE THAT THE
INSURANCE COMPANY MAY RELY ON THIS APPLICATION AND THE INFORMATION CONTAINED IN MY DRIVING RECORD AND THE DRIVING
RECORDS OF THE OTHER OPERATORS, SAID DRIVING RECORDS I NOW GRANT THE INSURANCE COMPANY PERMISSION TO OBTAIN. I
UNDERSTAND THAT THE POLICY WILL BE NULL AND VOID IF THE CHECK PRESENTED TO THE AGENT, BROKER, MGA OR COMPANY FOR
THE INITIAL POLICY IS RETURNED BY THE FINANCIAL INSTITUTION FOR ANY REASON. I FURTHER UNDERSTAND THE INSURANCE
PREMIUMS FOR THE ABOVE COVERAGE ARE SUBJECT TO CHANGES BASED ON THE SAID DRIVING RECORDS. I UNDERSTAND AND AGREE
THAT IF THE REPRESENTATIONS CONTAINED HEREIN ARE FALSE OR MISLEADING, SAID MISREPRESENTATIONS SHALL BE DEEMED
MATERIAL AND MAY RESULT IN CANCELLATION OF THIS POLICY AND DENIAL OF ALL OR PART OF THE COVERAGE PROVIDED IN THE
POLICY FOR WHICH I AM APPLYING.
A
NY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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
A
ND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICANT'S SIGNATURE DATE TIME PRODUCER'S SIGNATURE
A
CI-BA 04/05
A
CI-BA 04/05
Date
Signature of Produce
r
Signature of Insured
Policy #
Named Insured
I choose to reject both Uninsured and Combined Uninsured/Underinsured Motorist Coverage
I choose combined Uninsured/Underinsured Motorist Coverage at all limits o
f
; Property Damage Bodily Injury
I choose to reject combined Uninsured/Underinsured Motorist and select Uninsured Motorist coverage at all
; Property Damage
limits of Bodily Injury
(CHOOSE ONLY ONE OF THE FOLLOWING)
5.
4.
3.
2.
The UM and UM/UIM limits shown for vehicles on this policy may not be added to determine the total amount o
f
coverage provided.
UM and UM/UIM bodily injury limits up to $1,000,000 per person and $1,000,000 per accident are available.
UM property damage limits up to the highest policy property damage liability limits are available. Coverage fo
r
property damage is applicable only to damages caused by uninsured motor vehicles.
My selection or rejection of coverage below will apply to any renewal, reinstatement, substitute, amendment,
altered, modified, transfer or replacement policy with this company, or affiliated company, unless a named
insured makes a written request to the company to exercise a different option.
My selection or rejection of coverage below is valid and binding on all insured and vehicles under the policy,
unless a named insured makes a written request to the company to exercise a different option.
1.
Uninsured Motorist Coverage (UM) and Combined Uninsured / Underinsured Motorist Coverage (UM/ UIM) and
coverage options are available to me. I understand that:
SELECTION / REJECTION FORM
UNINSURED MOTORIST COVERAGE
COMBINED UNINSURED / UNDERINSURED MOTORIST COVERAGE
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Business Auto Application Phone 888-495-4950 Fax (Strickland Insurance Brokers)

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Completed 17 July 2021

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