Fillable CHUBB COLLECTOR CAR UNDERWRITING SUPPLEMENT (Colonial General Insurance Agency, Inc)

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CHUBB COLLECTOR CAR UNDERWRITING SUPPLEMENT (Colonial General Insurance Agency, Inc)

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CHUBB COLLECTOR CAR
UNDERWRITING SUPPLEMENT
AGENCY INFORMATION
A
GENCY CODE
A
GENCY NAME
PREFERRED EFFECTIVE DATE:
QUOTE/POLICY NUMBER:
APPLICANT INFORMATION
LAST FIRST
A
GENCY CODE
AGENCY NAME PHONE
DRIVER INFORMATION
L
ist ALL licensed members of household plus others who drive listed vehicle(s).
DRIVER
NAME DRIVER'S LICENSE NUMBER STATE LICENSED DATE OF BIRTH
1
2
3
4
DRIVER OCCUPATION RELATIONSHIP TO INSURED OPERATES COLL. VEH.? Y/N
% USE
1
2
3
4
DRIVER List ALL traffic convictions and claims reported for ALL drivers for the past 3 years. For claims, provide approximate amount paid.
1
2
3
4
COLLECTOR VEHICLE INFORMATION (attach additional pages as needed)
VEH. YEAR MAKE / MODEL / BODY TYPE
HIGH PERF
Y/N
STATE REGISTERED YEARS OWNED
CONDITION
(1 to 100 = Perfection)
1
2
3
4
VEH. AGREED VALUE* ANNUAL MILEAGE ODOMETER GARAGE LOCATION (If different than mailing address)
1
2
3
4
* Completion of High Value Supplemental Worksheet is required when the value of an individual vehicle is $500,000 and/or when the total collection is $1 million +
REGULAR USE VEHICLES
List ALL vehicles in household other than collectibles. Include non-owned company cars.
YEAR
MAKE / MODEL DRIVER CURRENT INSURER CURRENT LIABILITY LIMITS
PLEASE ANSWER THE FOLLOWING QUESTIONS
1. What is the total number of collector vehicles owned?
2. What is the total value of the collection?
3. Is any collector vehicle currently being repaired/restored?
If yes, what is the expected completion date?
Where is the vehicle being repaired/restored? (List name and address of shop)
4. Has (will) the original horsepower been increased or modified? Provide details.
5. Has (will) the engine, suspension, body, or drivetrain be changed? Provide details.
6. Are any collector vehicles used as a means of daily transportation, for errands or back-up transportation? If yes, explain.
7. Are any collector vehicles used for race/rally? If yes, provide details.
8. Are all collector vehicle(s) garage kept?
Is garage fully enclosed?
Is the garage kept locked?
9. Describe the security / fire detection systems in the garage, if any.
10. Is the garage part of a commercial building or business?
If yes, describe if / how the vehicles are separated from other activity and who has access to the site.
11. Is the garage located in a flood zone? If yes, what zone?
12. Is the garage located within 1 mile of the ocean?
13. If High Performance, what is the insured's prior experience driving such vehicles?
14. What automobile clubs does the insured belong to?
ADDITIONAL NOTES / REMARKS
Chubb, P.O. Box 1615, Warren, NJ 07061-1615
www.chubb.com/personal
Chubb refers to the insurers of the Chubb Group of Insurance Companies. Actual coverage is subject to
the language of the policies as issued.
Form 01-10-1515 (Ed. 1/08)
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CHUBB COLLECTOR CAR UNDERWRITING SUPPLEMENT (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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