Fillable COMMERCIAL AUTO FLEET INSURANCE APPLICATION (Risk Placement Services, Inc.)

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COMMERCIAL AUTO FLEET INSURANCE APPLICATION (Risk Placement Services, Inc.)

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CTP 5036 (03/10) Page 1 of 8
PO Box 2575 · Jacksonville, Florida 32203
904-363-0900 · 800-874-8053 · Fax 904-363-8093
COMMERCIAL AUTO FLEET
INSURANCE APPLICATION
New Business Renewal
GENERAL INFORMATION
Producer Name: Contact Name:
Date Coverage Desired: From: To:
Name:
Individual Partnership Corporation LLC Other:
Mailing Address:
Phone # (including area code):
Website: E-Mail Address:
Owner/Safety Inspection Contact? Name: Phone:
Garage Location(s):
(if different) Street Address State Zip Phone
Please list all owned terminals:
Location(s) # Units Address, City, State
Years In Trucking Industry: Business Start Date:
Federal ID # : US DOT Number:
Have you filed for Bankruptcy or Chapter 11 in the past
five years?
Yes No Are you presently in bankruptcy? Yes No
Please forward a current balance sheet and income statement.
DESCRIPTION OF OPERATIONS
For Hire Private Non-Trucking Other (explain):
Range of Transport Interstate Intrastate
Operations Beyond 300 Mile Radius
: Identify Metropolitan Areas Traveled Through or Into
Atlanta Dallas/Ft Worth Kansas City Mpls./St Paul Philadelphia San Diego
Balt-Washington Detroit Los Angeles New Orleans Phoenix San Francisco
Boston Houston Miami New York City Portland Seattle
Chicago
Cities other than above
or regular routes:
COMMODITIES TRANSPORTED
Commodity
% of
Loads
Maximum Value Commodity
% of
Loads
Maximum Value
$ $
$ $
$ $
$ $
GENERAL QUESTIONS
1. Are filings required?
Yes No If yes, list Base State, FHWA and All state and permit numbers where filings are
required:
Docket #:
Any Special Filings such as Oversize, Overweight, City Permits? Yes No
Give Details:
CTP 5036 (03/10) Page 2 of 8
2. Do you haul hazardous materials? Yes No
What Limits of Liability are required? $
3. Do you act as a freight-broker or freight-forwarder or arrange loads for others? Yes No
Docket #:
If yes, provide Brokerage Name:
Annual Brokerage Revenue: $
4. Are all owned trailers equipped with reflective tape? Yes No If no, attach a list of those trailers which are not.
( Check if listing attached.)
5. Is all equipment operated under the applicant’s authority scheduled on the application? Yes No
If no, attach explanation.
( Check if explanation attached.)
6. Is all owned equipment scheduled on this application? Yes No If no, attach explanation.
( Check if explanation attached.)
7. Is all the scheduled equipment owned by you? Yes No If no, attach explanation.
( Check if explanation attached.)
8. Do you pull doubles? Yes No Do you pull triples? Yes No
9. Do you haul containers or containerized freight? Yes No
10. Do you allow passengers other than company employees? Yes No If yes, attach a copy of passenger program
or explain program (frequency, requirements), etc.
( Check if explanation attached.)
11. Do you use any team, hot seat, slip seating or relay driver operations? Yes No
12. Is this a seasonal operation? Yes No If yes, describe:
13. Do you sign contracts with shippers that give the shipper the right to determine cargo salvage values or declare
cargos a total loss regardless of actual damage in the event of a loss?
Yes No
If yes, which shippers?
What are commodities for each shipper?
What is maximum load value? $
What is percentage of loads for signed contracts limiting salvage? %
14. Do you operate mobile equipment subject to compulsory or financial responsibility laws or other motor vehicle
insurance law in the state where it is licensed or principally garaged?
Yes No
15. Have you ever had Truck Insurance under another name? Yes No If yes, list name and DOT #:
Name DOT #
16. Do you carry Workers Compensation? If so, list the Carrier and Policy #
If not, do you provide Occ/Acc Coverage?
Yes No
LIENHOLDER INFORMATION
Attach Lienholder information for all insured units. ( Check if listing attached.)
LEASED OR HIRED
1. Do you sub-haul, lease or hire equipment from others? Yes No
If yes, is it:
Permanently Leased Trip Leased
a. If permanently leased, is it scheduled on this application? Yes No
b. If permanently leased, are autos hired with drivers?
Yes No
c. If trip leased, provide the annual estimated cost of hire:
Current Year: $ Prior Year: $
d. What is your percentage of sub-hauling? %
e. Attach a list with name and address of each Lessor. Provide a copy of each contract.
CTP 5036 (03/10) Page 3 of 8
2. Do you lease to others? Yes No If yes, who must provide primary insurance? You Other
If you provide insurance, is coverage desired for:
Named Lessee(s) All Lessees (Blanket Basis)
If Named Lessee(s), attach a list of Name and Addresses for each lessee.
( Check if listing attached.)
Provide a copy of each contract.
Insurance
Provided by
With
Driver
Without
Driver
Average
Duration of a
Trip Lease
Average # of
Trip Leases
Per Year
Estimated
Trip Lease
Payments
Per Year
Lessor Lessee
With Hold Harmless
Naming other Party
As Additional
Insured?
A.
From Others
Yes No
B.
To Others
Yes No
3. Under whose Bill of Lading is shipment moved when leased to others?
From Others?
4. What % of Deadheading? %
5. Do you backhaul? Yes No If yes, what do you backhaul?
SCHEDULE OF EQUIPMENT OPERATED
Provide schedule of equipment to include: Make, Model, Year, Type, Complete VIN Number, GVW, Garaging Location, Stated
Amount and Radius of Operation.
Type Owned
Leased w/o
Drivers
Owner
Operators
Local
(0-100)
Inter.
(101-300)
Long Haul
(Over 301)
TOTAL UNITS
Light Trucks
Medium Trucks
Heavy Trucks
Tractors
Semi-Trailers
Dump Trucks
Dump Trailers
Other
UNITS REVENUE AND MILEAGE / Actual and Estimated
Period Units / Revenue / Mileage
Projected
$ #
Current
$ #
1
st
Prior
$ #
2
nd
Prior
$ #
3
rd
Prior
$ #
4
th
Prior
$ #
Attach IFTA’s for past 4 quarters. ( Check if copies attached.)
Attach Current FYE Financial Statement including profit & loss statements and balance sheets. ( Check if copy attached.)
SUMMARY OF EQUIPMENT VALUES / Physical Damage - Unit Count
Total Fleet Value (Current): $ No. of Units (Current): #
Total Fleet Value (1
st
Prior): $ No. of Units (1
st
Prior): #
Total Fleet Value (2
nd
Prior): $ No. of Units (2
nd
Prior): #
Total Fleet Value (3
rd
Prior): $ No. of Units (3
rd
Prior): #
Total Fleet Value (4
th
Prior): $ No. of Units (4
th
Prior): #
Highest Tractor Value: $ Highest Trailer Value: $
Lowest Tractor Value: $ Lowest Trailer Value: $
CTP 5036 (03/10) Page 4 of 8
INSURANCE HISTORY & LOSS EXPERIENCE
HAS ANY INSURANCE COMPANY CANCELED OR NON-RENEWED YOUR POLICY IN THE LAST FOUR YEARS?
Yes No If yes, explain:
Is your current coverage presently under Cancellation or Non-Renewal?
Yes No
If yes, explain:
Furnish currently valued (value dated within the last 3 months) Insurance Company produced detailed loss / experience for auto
liability, physical damage and cargo. Loss runs must be for current
year plus 4 (four) prior policy years.
Policy Term
From To
Insurance Company # of Claims
/
Total Incurred
$
$
$
$
$
Describe any claim with payment or reserves over $25,000. ( Separate Sheet Attached - If necessary. )
Date of Loss
Amount of Loss /
Reserve
Driver Involved
in Loss
Description of Loss
$
$
$
$
$
DRIVERS
1. Truck Fleet – No. of Drivers: Regularly Employed Part Time
Owner Operators Leased
Casual
TOTAL
2. How are drivers paid? Hourly Trip Mileage Other:
3. Drivers Hired or Leased Last Year
Company Drivers
Leased Owners/Operators
Number replaced
Number increased
4. Age of Drivers: What is the minimum acceptable age of any driver:
5. Do you employ or hire drivers with less than 2 years commercial driving experience with like kind of equipment?
Yes No If yes, explain.
6.
Do you use the driver information available through the Driver Information Resource System (DIRS) in your driver
hiring and management practices?
Yes No
7.
Are your driver hiring and qualification standards based on DSMS classifications? Yes No
Do your driver management practices follow these standards without exception?
Yes No
8. Do all your drivers speak fluent English? Yes No
9.
Do presently employ drivers with any of the following? (check all that apply)
Younger than 23 years old.
Three (3) moving violations in three (3) years.
DUI violation.
Two preventable accidents.
49 CFR391.41 medical causes.
Refusal of drug or alcohol test.
Positive tested drivers.
Invalid CDL drivers via suspension or revocation.
Failing or refusing to submit driver logs.
CTP 5036 (03/10) Page 5 of 8
Provide a list of drivers that includes: Driver’s Name, DOB, License Number and State, Unit Normally Driven, Date of
Hire and Years of Driving Experience
( Check if listing attached.)
Provide a copy of hiring criteria (standards) for all new and current drivers. ( Check if copy attached.)
SAFETY AND MAINTENANCE
1. Do you have a Formal Safety Program? Yes No
2. Name, title, phone number of person responsible for safety (specify other duties):
3. Are you operating your trucks with speed governors? Yes No
If yes, what speed are they set at?
4. Are electronic log programs used to audit driver log books? Yes No
5. Do you utilize any satellite tracking systems? Yes No
6. Is there a written cell phone/texting policy in effect? Yes No Acknowledged in writing by all drivers? Yes No
7. Do you perform annual Appendix G Inspections as required in Part 396 of the FMCSR? Yes No
8. Do you perform regular PM Services? Yes No How often?
9. Do you follow up on driver reported maintenance issues? Yes No
10. Have driver reported maintenance complaints been addressed in a timely manner? Yes No
11. Who performs maintenance on Owner/Operator equipment?
12. Provide your Carrier Safety Measurement System (CSMS) rating and indicate any changes over the past two (2) years.
COVERAGES
Auto Liability
Combined Single Limit (CSL) $ CSL
Deductible* $
( *Loss Fund Agreement Required. Sample available upon request. )
Non-Ownership Liability # of Employees:
Hired Auto Liability Estimated Cost of Hire:
Reporting Basis If reporting, indicate basis: Revenue Mileage
Uninsured / Underinsured Motorist and No-Fault
Uninsured Motorist** $
Personal Injury Protection $
Underinsured Motorist** $
Medical Payments $
** Coverage and limit choices in this section are for quoting purposes only.
A separate Carolina Casualty and/or ISO Uninsured Motorists / Underinsured Motorist selection/rejection form(s)
must be completed and signed by the applicant when completing the application.
Trailer Interchange
(Provide Copy of Agreement)
# of Trailers: #
Maximum Trailer Value $ # of Trailer Days: #
Comprehensive OR $
Specified Perils $
Collision $
Physical Damage
Comprehensive OR $ Deductible
Total Insured Values:
$
Specified Perils $ Deductible
Collision $ Deductible
Extended Towing Limit $ $5,000 included – Enter amount if higher limit requested.
Non-Owned Trailer Limit $
CTP 5036 (03/10) Page 6 of 8
Cargo
Limit $
Deductible $
Temperature Control Equipment Breakdown (Note a $2,500 deductible applies to this option.)
Optional Cargo Coverages
Temperature Control Equipment Breakdown - minimum $2,500 deductible applies to this option.
Water Damage / Tarpaulin Endorsement – minimum $2,500 deductible.
Poultry Cages (Non-owned) Endorsement
Other
Special Limits Endorsement Limit $ Shipper Commodity
% of Loads @ higher limit
Terminal Coverage Limit $ Deductible $
Other
Physical Address
Describe Facility
Describe Security Features
Combined Deductible (Physical Damage / Cargo)
A combined deductible will apply unless declined.
Combined Deductible applies to Tractor / Trailer only.
Combined Deductible applies to Tractor / Trailer and Cargo (if written).
I / We DECLINE the Combined Deductible.
CAROLINA CASUALTY INSURANCE COMPANY LOSS PREVENTION SERVICES
9 CCIC’s Loss Control staff can tailor loss control consultative services to meet your specific needs.
9 Our Loss Control staff is available to our insured’s to provide a D.O.T. audit compliance review so that insured will be prepared for
a D.O.T. compliance audit before it happens.
9 CCIC insureds can take advantage of our Safe Driver Awards Program.
9 Our Loss Control staff will help our insureds conduct effective safety meetings.
9 Seminars are available to CCIC insureds to help with continuing education of your drivers and other staff members.
NOTICE TO CALIFORNIA APPLICANTS: ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE
COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT
APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
AN INSURER WHICH REFUSES TO PROVIDE COVERAGE TO AN APPLICANT WHO IS A "GOOD DRIVER" MUST PROVIDE THE APPLICANT
WITH WRITTEN STATEMENT OF THE REASONS IT DENIED COVERAGE. IN GENERAL, UNDER CALIFORNIA LAW A GOOD DRIVER IS A
PERSON WHO HAS NOT HAD MORE THAN ONE VIOLATION POINT OR MORE THAN ONE AT-FAULT ACCIDENT RESULTING IN ONLY
PROPERTY DAMAGE IN THE LAST THREE YEARS.
NOTICE TO COLORADO APPLICANTS: 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 REWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE
COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN
INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN
ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED
BY THE APPLICANT.
NOTICE TO FLORIDA APPLICANTS: 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.
CTP 5036 (03/10) Page 7 of 8
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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.
NOTICE TO MAINE & VIRGINIA APPLICANTS: 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 OR DENIAL OF INSURANCE BENEFITS.
NOTICE TO MICHIGAN APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES
AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE
SUBJECT TO IMPRISONMENT FOR UP TO ONE YEAR FOR A MISDEMEANOR CONVICTION OR UP TO TEN YEARS FOR A FELONY
CONVICTION AND PAYMENT OF A FINE OF UP TO $5,000.00.
NOTE: CONSUMER ASSISTANCE MATERIAL IS AVAILABLE FROM THE MICHIGAN INSURANCE BUREAU, PO BOX 30220, LANSING, MI
48909-7720; 517-373-0240
NOTICE TO MINNESOTA APPLICANTS:
THE INSURER MAY ELECT TO CANCEL COVERAGE AT ANY TIME DURING THE FIRST 59 DAYS FOLLOWING
ISSUANCE OF THE COVERAGE FOR ANY REASON WHICH IS NOT SPECIFICALLY PROHIBITED BY STATUTE.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR
PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO IN CONNECTION WITH SUCH
APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A
FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT
AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH
IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE
SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
NOTICE TO OHIO APPLICANTS:
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER
FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION,
BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND THE PAYMENT OF A FINE OF UP TO $15,000.
NOTICE TO SOUTH CAROLINA APPLICANTS THE INSURER CAN CANCEL THIS POLICY FOR WHICH YOU ARE APPLYING WITHOUT
CAUSE DURING THE FIRST 90 DAYS. THAT IS THE INSURER'S CHOICE. AFTER THE FIRST 90 DAYS, THE INSURER CAN ONLY CANCEL
THIS POLICY FOR REASONS STATED IN THE POLICY.
IF I AM REQUESTING INSURANCE FOR ANY INDIVIDUALLY OWNED PICKUP TRUCK, PANEL TRUCK, VAN, OR SIMILAR MOTOR VEHICLE,
AND I HAVE PREVIOUSLY USED THE VEHICLE(S) IN MY BUSINESS, I HAVE PROVIDED AS AN ATTACHMENT TO THIS APPLICATION
EITHER A COPY OF MY BUSINESS LICENSE, OR A COPY OF IRS FORM 1040, SCHEDULE C OR SCHEDULE C-EZ, DETAILING NET PROFIT
OR LOSS DERIVED FROM THE LEGITIMATE COMMERCIAL USE OF THE VEHICLE(S). IF I HAVE NOT PREVIOUSLY USED SUCH VEHICLE(S)
IN MY BUSINESS, OR IF I HAVE A NEW COMMERCIAL ENTERPRISE, I HAVE READ AND SIGNED THE SOUTH CAROLINA COMMERCIAL
AUTO SUPPLEMENT, ACORD 62 SC.
NOTICE TO UTAH APPLICANTS: ANY MATTER IN DISPUTE BETWEEN YOU AND THE COMPANY MAY BE SUBJECT TO ARBITRATION AS
AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER
RECOGNIZED ARBITRATOR. A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE COMPANY. ANY DECISION REACHED BY
ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY. THE ARBITRATION AWARD MAY INCLUDE ATTORNEY’S FEES,
IF ALLOWED BY STATE LAW AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT OF PROPER JURISDICTION.
CTP 5036 (03/10) Page 8 of 8
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT OR OTHER INVESTIGATIVE REPORT, MAY
BE COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT
RENEWALS. ANY INFORMATION WHICH WE HAVE OR MAY OBTAIN ABOUT YOU OR OTHER INDIVIDUALS LISTED AS POLICYHOLDERS
ON YOUR POLICY WILL BE TREATED CONFIDENTIALLY. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED
INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT
YOUR AUTHORIZATION FOR SUCH PURPOSES AS CLAIMS HANDLING, SERVICING, UNDERWRITING AND INSURANCE MARKETING. YOU
HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES.
A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON
REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM FOR PAYMENT OF A LOSS OR BENEFIT CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH MAY BE, OR IN SOME STATES IS, A CRIME AND SUBJECTS THE PERSON
TO CRIMINAL AND CIVIL PENALTIES. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY
TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
COVERAGE HAS NOT COMMENCED. You, or your agent, may commence coverage only by requesting a licensed general agent of Carolina
Casualty Insurance Company to bind coverage. A binder of insurance will be issued by our licensed general agent specifying the date and
time coverage will become effective, but in no event shall coverage become effective prior to the date and time you, or your agent, contact a
licensed general agent of Carolina Casualty Insurance Company and coverage is bound by him or her.
SIGNATURES
I hereby certify that the information contained in this application is true and agree that a misrepresentation of any of the facts by
me will constitute a reason for the company to void or cancel any policy issued on the basis of this application and will hold the
company harmless for the action taken. I also agree that if a policy is issued pursuant to this application, the application and
any elections or rejections, which are included with the application and signed by me, may be relied upon by the company as
accurate and shall become part of the policy.
I recognize that all or parts of my operations are under the Department of Transportation oversight requiring me to adhere to
their rules and regulations, acknowledge that DOT’s rules and regulations are understood by me and I will adhere to the rules
and regulations including, but not limited to, driver hiring, vehicle inspection and maintenance, and hours of service.
I authorize Carolina Casualty Insurance Co to obtain a copy of any Motor Vehicle Report for rating/underwriting the insurance
for which I have applied. I also understand that a routine inquiry may be made providing information concerning my character,
general reputation, personal characteristics and mode of living. Upon written request, information as to the nature and scope of
the report will be provided to me.
Signature of
APPLICANT
X
Signature of AGENT of
Applicant
X
Type or print Applicant
Name:
Agency Name:
Address of
Agency:
Title or relationship to
Applicant:
Agent License or
Registration #:
Agent Phone Number:
Licensed Agent of the
Company:
Date Application
Completed:
Licensed Agent ID#:
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COMMERCIAL AUTO FLEET INSURANCE APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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