COMMERCIAL APPLICATION SUPPLEMENT
(USE WITH: CTP 5037 and CTP5307)
PO Box 2575 · Jacksonville, Florida 32203 ·
904-363-0900 · 800-874-8053 · Fax 904-363-8093
CTP 5725 (12/07) Page 1 of 2
APPLICANT NAME: DATE:
APPLICANT TRADE (DBA) NAME:
LIST OF DRIVERS OF INSURED VEHICLES (attach list of drivers with required information if space below is not adequate)
No. of Accidents, Convictions and
Violations in Last Three Years
Driver’s Name
Class
A, B, C
Original
CDL
License
Date
Date of
Birth
Driver’s
License
State
Driver’s License
Number
Accidents Violations
No. of serious
violations in
last 7 years (1)
Date of
Hire
Years
Driving
Similar
Vehicle
A
A
A
A
A
A
A
A
A
A
(1) Serous violations include, but are not limited to: DUI, homicide or assault involving an auto, leaving the scene of an accident, etc.
DESCRIPTION OF VEHICLES (Trailers must be scheduled for coverage to apply while detached from power unit.)
Unit
No.
Model
Year
Manufacturer Vehicle Type (truck, tractor,
trailer, mobile equipment, etc.)
Serial Number (17 digit) Radius Truck GVW
Tractor GCW
Owner
Type *
6 N
7 N
8 N
9 N
10 N
11 N
12 N
13 N
14 N
15 N
* N=Owned by Named Insured; L=Owned by Leasing Co. (long term lease without driver); O=Owned by Owner Operator; E=Owned by Employee of Named Insured (Officer).
Percent of trips by radius
0 - 50 51 - 300 Over 300
Trailer*
Pulled
Primary commodities hauled
(list top 3 commodities for each power unit)
6 D
7 D
8 D
9 D
10 D
11 D
12 D
13 D
14 D
15 D
* Trailer type or type trailer pulled by power unit – D = dump, F = flatbed, P = pole/logging, R = reefer, T = tank, V = dry van, A = auto hauler
