Fillable COMMERCIAL TRUCK FLEET INSURANCE APPLICATION (Strickland Insurance Brokers)

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COMMERCIAL TRUCK FLEET INSURANCE APPLICATION (Strickland Insurance Brokers)

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COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
1
Canal Insurance Canal Indemnity Proposed Effective Date: ________________ Expiration Date: ___________________
New Policy No: _____________________ Renewal Policy No: _____________________ Date Quote is needed: ______________
GENERAL INFORMATION
Individual LLC Partnership Corporation
Other ________________________________
General Agency: Name ________________________ Code ___________
Producing Agency: Name ________________________ Code ___________
Applicant Name
Company Name (DBA) (if any)
Phone #
Cell Phone #
US DOT #
Month/Year Current Operations Began
Location of the Business or Physical Address, if different
City
State
Zip
Location is:
Inside City Limits Outside City Limits
Company Website
Mailing Address
City
State
Zip
Safety Director
Safety Director Phone #
Operations Director Name
Operations Director Phone #
Safety Director Email Address
Years in Current Position
Operations Director Email Address
Years in Current Position
Safety Director Address
Operations Director Address Title
FOR VIRGINA APPLICANTS ONLY: Read your policy. The policy of insurance for which this application is being
made, if issued, may be cancelled without cause at the option of the insurer at any time in the first 60 days during
which it is in effect and at any time thereafter for reasons stated in the policy.
MARYLAND NOTICE OF UNDERWRITING PERIOD ADVISORY NOTICE TO POLICYHOLDERS: We are notifying you
that the policy you have just agreed to purchase is subject to a 45 day underwriting period beginning on the
effective date of your coverage. Your coverage may be cancelled during the underwriting period if your risk does
not meet our underwriting standards. If we decide to cancel the policy, we will send you a written notice of
cancellation advising you of the reason(s) for the cancellation and the date on which your policy will be cancelled.
Your premium may be recalculated during the underwriting period due to discovery of a material risk factor. If we
recalculate the premium, we will send you a written notice of recalculation of premium advising you of the amount
of and reason for the recalculated premium.
FOR SOUTH CAROLINA APPLICANTS ONLY: 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.
OWNER / PRINCIPAL / PRESIDENT
Name
Title
Home Address
Apt #
City
State
Zip
Business Phone
Range of Transport: Interstate Intrastate
Brokerage: Do you have Brokerage Authority? _______________ Under the same name? ___________________
Do you broker both exempt & non-exempt loads? ____ If yes, % of brokerage under same name ____%
Percent of Loads:
(Local) 0 – 150 Miles ______ (Intermediate) 151 – 300 Miles ______ (Long Haul) 301 – 500 Miles ______ (Long Haul) 501 Miles + _________
Longest Trip One Way _____________ Miles Annual Miles Driven _________________ Miles
DESCRIPTION OF OPERATIONS
Business
Class
Trucking For Hire – Exempt Trucking for Hire – Nonexempt Manufacturer Retailer Agriculture
Mining Wholesale Distributer Service Construction Forestry
Operations
Auto – Boat Haulers Commercial Use – Truck Container/Intermodal Contractors Courier/Specialized Del.
Drive-away Dry Bulk / Farm Products Dry Van/Box Dry Van – Doubles Dump
Dump-Coal Flatbed Livestock Log or Pulp Mobile Home
Non-Trucking Refrigerated PPT – Corporate Owned Service Truck Special Type Operations
Tanker-Fuel Tanker – Liquids/Comp. Gases Towing & Recovery Waste/Garbage Other ____________
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
2
LIST CITY DESTINATIONS BELOW
1.
2.
3.
4.
OPERATIONS BEYOND 300 MILES RADIUS: Identify Metropolitan Areas Traveled Through Or Into
Atlanta
Cleveland
Jacksonville
Milwaukee
Orlando
Salt Lake City
Balt-Washington
Dallas/Ft Worth
Kansas City
Mpls./St Paul
Philadelphia
San Diego
Boston
Denver
Little Rock
Nashville
Phoenix
San Francisco
Buffalo
Detroit
Los Angeles
New Orleans
Pittsburgh
Seattle
Charlotte
Hartford
Louisville
New York City
Portland, OR
Tampa
Chicago
Houston
Memphis
Oklahoma City
Richmond
Tulsa
Cincinnati
Indianapolis
Miami
Omaha
St. Louis
_____________
Alabama, Mississippi, Louisiana
Connecticut, Maine, Massachusetts,
New Hampshire, Rhode Island, Vermont
Delaware, Maryland, New York, New Jersey,
Pennsylvania
Florida, Georgia, North Carolina,
South Carolina, Virginia
Cities other than above or regular routes ____________________________________________________________________________________
Top Customers:
1. ______________________________ _____ % Load 2. ______________________________ _____ % Load 3. ______________________________ _____ % Load
Commodity
% of Loads
Maximum Value
Commodity
% of Loads
Maximum Value
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?
If yes, attach a copy of the contract.
SCHEDULE OF EQUIPMENT OPERATED
TYPE
Owned
Leased w/o Drivers
Owner Operators
Local (0-150)
Intermediate (151-300)
Long Haul (301+ miles)
TOTAL UNITS
Auto or Service
Light Trucks
Medium Trucks
Heavy Trucks
Tractors
Semi-Trailers
REPORTING OPTION – UNITS, REVENUE OR MILEAGE (Actual and Estimated)
Period
Units
Revenue
Mileage
Projected
Current
1
st
Prior
2
nd
Prior
3
rd
Prior
4
th
Prior
PAYMENT OPTIONS
Annual Policy: Full Payment to Company Company Payment Plan ______ % Down payment _____ # of installments
Financed through outside Premium Finance Company with full payment to Canal (no double financing permitted – attach contract)
Continuous Until Cancelled Policy (Escrow deposit and monthly billing will be required.) ______ % Deposit
FILINGS
Filings Requested
MC # / Cert. #
Applicant’s Name and Address Exactly As It Appears On Each Permit
Liability BMC 91X
Liability – Form E ____State
Oversized/Overweight ____State
Hazardous ____State
Intermodal
Cargo – Form H ____State
DMV ____State
SR 22 – If yes explain
Other __________________
Please note: The FMCSA and/or state agencies require a minimum 36 day notice of cancellation on all policies that have a MCS-90 or other filings.
COMMODITIES TRANSPORTED
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
3
CURRENT CARRIER
Current Carrier Name ______________________________________________________________________ Policy Number _______________________________
Policy Limits _______________________________
Policy Dates _________________________ TO _________________________
Policy Deductible BI __________________________________________ PD __________________________________________
Current Rate / Exposure Basis
_____________________________________________
CERTIFICATE OF INSURANCE
Name
Mailing Address
SUMMARY OF EQUIPMENT VALUES
Total Fleet Value
# of Units
Average Value
Total Tractor Value
# of Units
Average Value
Total Trailer Value
# of Units
Average Value
Highest Tractor Value
Highest Trailer Value
Lowest Trailer Value
LIENHOLDER AND/OR PAYEE INFORMATION
UNIT #
NAME
ADDRESS
1
2
3
Non-Owned Trailers
1
2
3
QUESTIONNAIRE
YES NO
1. Is all equipment operated under the applicant’s authority scheduled on the application? If no, attach explanation.
2. Is all owned equipment scheduled on this application? If no, attach explanation
3. Do you lease your vehicles to others? If yes, who must provide liability coverage?
You Lessee
4. Do you hire other motor carriers or owner-operators to haul for you?
If yes, complete question below, complete Hired Autos Application Supplement and attach copy of lease agreement. If no, skip to question #5.
A. On what basis are they leased?
Permanent Basis
Temporary/Trip Basis
B. Provide annual cost of hire or # of trips
_______________________
_______________________
C. Are vehicles leased with driver?
Yes No
Yes No
D. Are leased vehicles included in this application for insurance?
(1) If yes, do you require leased vehicle owners to purchase non-trucking liability coverage?
Yes No
Yes No
(2) If no:
a. Is there a written lease agreement stating the lessor will provide primary auto liability
coverage while leased to you?
Yes No
Yes No
b. Limit of Liability required
Yes No
Yes No
c. Do you secure evidence the lessor has primary auto liability coverage?
Yes No
Yes No
d. Does the lease state that the lessor agrees to provide you with 30 days advance notice if
their insurance coverage is being cancelled or reduced?
Yes No
Yes No
5. Do you pull doubles?
6. Do you haul intermodal containers?
7. Is any portion of your operation seasonal? If yes, explain. __________________________________________________
8. Do you use any team, hot seat, slip seating or relay driver operations?
9. Do you allow passengers other than company employees? If yes, attach copy of passenger program or explain program (frequency, requirements), etc.
10. Do you operate more than one terminal? If yes, provide the following
LOCATION(S)
# UNITS
Address, City, State
11. Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged? If
yes, and need Liability Coverage, complete Mobile Equipment Supplement.
12. Do you require use of escort vehicles?
If yes and escort vehicles are not included in this application for insurance, provide the name of the insurance carrier, policy number and auto liability limits.
If yes and escort vehicles are included in this application, drivers of escort vehicles should be listed in the Driver Information Section.
13. Do you haul oversized, overweight or hazardous loads? If yes, attach explanation.
14. For Non-Trucking accounts, does the insured lease to other companies? If yes, what is the DOT # of the other entity? _____________
15. Is there GAP coverage for vehicles with Physical Damage?
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
4
ADDITIONAL UNDERWRITING INFORMATION
In the past five years, have any drivers been convicted of any of the following? Yes No
Leaving the scene of an accident or a hit and run, any felony conviction which involves a motor vehicle, driving while license is suspended or revoked in a commercial vehicle, DUI or DWI.
If yes, please provide driver name, conviction date and details: _________________________________________________________________________
In the past three years, have any drivers been convicted of any of the following? Yes No
Negligent homicide, unlawful use of vehicle, speed contest or racing, reckless driving, or speeding twenty miles or more over the speed limit.
If yes, please provide driver name, conviction date and details: _________________________________________________________________________
For Kansas applicants only: Convictions for exceeding a maximum posted speed limit of 30 to 54 MPH by six MPH or less or exceeding a maximum posted speed limit of 55
to 70 MPH by 10 MPH or less shall not be considered by any insurance company in determining the rate charged for any automobile liability policy.
TRUCKERS GENERAL LIABILITY COVERAGE
YES NO
Do you haul bulk fuel?
Do you repair or service vehicles of others?
Do you have dogs at premises? (see exclusion endorsement)
Do you or anyone else who is an employee carry a firearm to work? (see exclusion endorsement)
Do you generate income from other activities besides the operation of the trucks?
Do you want to add Contractual Liability
Do you want to add mis-delivery of goods Coverage?
Do you have fuel storage containers on premises?
Please list all mobile equipment owned by the applicant, if any (i.e. forklift, backhoe, mobile crane, etc.)
Please list all premises owned or rented
Street Address
City
State
Zip
County
Description of any other operations being conducted by this applicant?
ADDITIONAL/DESIGNATED INSUREDS FOR AUTO LIABILITY OR TRUCKERS GENERAL LIABILITY
Name
Mailing Address
*Type of Additional Insured
* Please enter each desired additional/designated insured by entering the corresponding number and/or letter:
Auto Liability Additional Insureds: 1. Designated Additional Insured, 2. Intermodal, 3. Additional Insured Waiver Rights Recovery.
General Liability Additional Insureds: A. Controlling Interest, B. Designated Person or Organization, C. Managers or Lessors of Premises, D. Mortgagee, E. Owners, Lessees or Contractors, F. Co-owner
of Insured Premises, G. Vicarious Liability of Owners, Lessees or Contractors.
INSURANCE HISTORY AND LOSS EXPERIENCE
Provide the following insurance and loss information for the current year plus at least four (4) full prior policy years.
HAS ANY INSURANCE COMPANY CANCELLED OR NONRENEWED YOUR POLICY IN THE LAST FOUR (4) YEARS?
(Missouri Applicants – Do not answer this question.)
Yes No If Yes, explain.
_________________________________________________________________________________
Policy
Insurance
Policy
Liability
Phys Dam
Cargo
General Liability
Term
Company
Number
#
Loss Amt.
#
Loss Amt.
#
Loss Amt.
#
Loss Amt.
Please enter the # of claims over $100,000: _____________
Please enter the dollar amount for claims over $100,000: ___________________
EXPERIENCE INFORMATION: Furnish currently valued (must be value dated within the last 3 months) insurance company produced detailed loss and experience
auto liability, physical damage and cargo loss runs for current year plus at least four (4) full prior policy years.
Describe any claim with payment or reserves over $25,000.
_________________________________________________________________________________________________________________________
NOTICE FOR MARYLAND APPLICANTS: Canal’s acceptance of this application is contingent upon the consideration of the applicant’s claims history. If accepted,
your claims history will also be considered in determining if the policy should be cancelled or non-renewed.
A-101 Fleet(10-2013)
A-101 Fleet(10-2013)
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
5
DRIVER INFORMATION
Provide a list of drivers that includes the Driver’s Name, DOB, License Number, Date of Hire and Years of Driving Experience.
Truck Fleet – No. of drivers:
How are drivers paid?
Regularly Employed ________ Part Time ________ Owner/Operator _______
Leased ________ Casual ________ TOTAL ________
Hourly Trip Mileage Other: ________________________________
Drivers Hired or Leased Last Year
a. Number replaced _________
b. Number increased _________
c. Minimum Age _________
Company Drivers
____________________________________________
____________________________________________
____________________________________________
Lease/Owner Operators
________________________________________
________________________________________
________________________________________
DRIVER HIRING, TRAINING AND SAFETY
1. Which of the following is part of your driver screening/hiring process:
Employment background check Pre-employment drug test
Criminal background check Road Test
Motor Vehicle record (MVR) review Pre-employment Screening Program (PSP) Report for FMCSA
Behavioral / Integrity Testing Physical Abilities Testing
2. Which of the following is part of your driver performance management process:
Annual review of driver’s driving record (MVR) Review of electronic engine data
Periodic review of driver and vehicle out of service violations. (SafeState/CSA2010 Reports) Incentives for violation-free and accident-free driving
Are Owner Operators subject to Motor Carrier Maintenance Programs, i.e. EOBR/Qualcomm Formal corrective action procedures. If so, please attach.
Periodic review of accidents/incidents Driver safety training? Description of Program ________________________________
Are units governed? If so, what limit __________? Formal Written Hiring Standard. If so, please attach.
3. Do you adhere to a written vehicle inspection and maintenance program? Yes No
If yes, describe or attach program. _______________________________________________________________________________________________________________________________
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
6
COVERAGES
AUTO LIABILITY LIMITS: $ ______________________ CSL
LIABILITY FOR NON-TRUCKING USE
Leased to: _____________________________________________________
LIMITS: $ ______________________ CSL
HIRED AUTO LIABILITY
Cost of Hire ____________________
NON-OWNED Is the account a Service or Charitable Organization? Yes No # of Power units under agreement ___________
MEDICAL PAYMENTS Limits _______________________
Property Protection (Michigan Only)
Property Damage Buyback (Michigan Only)
Medical Expense (Virginia Only)
Income Loss Benefits (Virginia Only)
New York Spousal Liability Coverage (New York Only)
PHYSICAL DAMAGE (Please refer to Vehicle Information Section for Stated Amount values by Vehicle.)
Comprehensive $__________Deductible Collison $__________Deductible Specific Cause of Loss (SCoL) $__________Deductible
TOWING Amount of Coverage $_____________
RENTAL REIMBURSEMENT Amount Per Day $__________ for 30 days.
ROADSIDE SERVICE
TRAILER INTERCHANGE
Provide a Copy of Agreement
# of Power units under agreement ___________ Maximum trailer value $____________ # trailer days per power unit ______________
NON-OWNED TRAILER LIMIT Limits _______________________ Provide a Copy of Agreement
ENHANCED PHYSICAL DAMAGE Standard Preferred
HIRED AUTO PHYSICAL DAMAGE Complete and Attach Supplement
CARGO Limit $___________________ $___________________Deductible (Same for all vehicles with Cargo Coverage)
OPTIONAL CARGO COVERAGES: (Check all that apply)
Refrigeration Breakdown – $2,500 deductible applies Earned Freight Increase to $________ ($1,000 included)
Debris Removal Increase to $____________________ ($25,000 Included)
UNINSURED/UNDERINSURED MOTORIST AND NO-FAULT OPTIONS
UNINSURED MOTORISTS BODILY INJURY Limits: _______________
UNDERINSURED MOTORISTS BODILY INJURY Limits: _______________
UNINSURED MOTORISTS PROPERTY DAMAGE Limits: _______________
PERSONAL INJURY PROTECTION Limits: _______________ Are drivers covered by Workers Compensation? Yes No
Coverage and limit choices in this section are for quoting purposes only. A separate Supplemental Uninsured Motorist/Underinsured Motorist and
Personal Injury Protection Form may be required to be completed and signed by the applicant when binding coverage.
TRUCKERS GENERAL LIABILITY COVERAGE SELECTION This is for businesses solely involved in “For-Hire” transportation of property.
Desired Aggregate Limits – please select one $,1,000,000 $2,000,000 Each Occurrence $1,000,000 (included)
Employers Liability (Stop Gap) Coverage – Applicable only in ND, OH, WA and WY. Please select either yes or no.
Yes No $1,000,000 Bodily Injury by Accident – each accident $1,000,000 Bodily Injury by Disease – each employee
$1,000,000 Bodily Injury by Disease – each policy
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
7
FRAUD STATEMENTS
ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution, fines, or confinement in prison, or any combination thereof.
ALASKA and VERMONT: Any person who knowingly and with intent to injure, defraud, or deceive any insurance
company files a statement of claim containing any false, incomplete or misleading information may be prosecuted
under state law.
DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement
of claim containing any false, incomplete or misleading information is guilty of a felony.
ARKANSAS, LOUISIANA, RHODE ISLAND and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
ARIZONA: Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
CALIFORNIA: For you protection, California law requires the following to appear on this form. Any person who
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
COLORADO: 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 for
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other 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.
FLORIDA: Any person who knowingly, and with intent to injure, defraud or deceive any insurance company files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement
containing any false, incomplete or misleading information is guilty of a felony.
INDIANA: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any
false, incomplete, or misleading information commits a felony.
KANSAS: Any person who, knowingly and with intend 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.
KENTUCKY: 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.
A-101 Fleet(10-2013)
A-101 Fleet(10-2013)
A-101 Fleet(10-2013)
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
8
MAINE, TENNESSEE, VIRGINIA and WASHINGTON: 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.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit or who 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.
NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a
statement of claim containing any false, incomplete or misleading information is subject to prosecution and
punishment for insurance fraud as provided in RSA 638:20.
NEW YORK: 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.
NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil
fines and criminal penalties.
OHIO: Any person who, with intent to defraud or knowing that he 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.
OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by
submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating
state law.
PENNSYLVANIA: GENERAL: 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.
TEXAS: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in state prison.
UTAH: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed by
false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or
billing for health care fees or other professional services is guilty of a crime and may be subject to fines and
confinement in state prison.
ALL OTHER STATES: Any 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 and subjects the person to criminal and civil penalties.
A-101 Fleet (10-2013)
COMMERCIAL TRUCK FLEET
INSURANCE APPLICATION
A-101 Fleet (10-2013)
9
ACKNOWLEDGEMENT AND SIGNATURE
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 reason for the Company to 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 a part of the policy
I understand and acknowledge that uninsured, underinsured and no-fault coverage, where applicable and/or required,
have been offered to me. I have selected the limit(s) indicated on this application unless other limits are indicated and
selected on a supplemental selection/rejection form.
I understand that the coverage selection and limit choices indicated herein will apply to all future policy renewals,
continuation and change unless I, or my agent, notify Canal Insurance Company otherwise in writing.
Signature of APPLICANT ________________________________
Type or Print Applicant Name ________________________________
Title or Relationship to Applicant ________________________________
Date and Time Application Completed ________________________________
Requested Effective Date and Time ________________________________
Phone # of Applicant ________________________________
Fax # of Applicant ________________________________
Signature of AGENT ________________________________
of the Applicant ________________________________
Agency Name ________________________________
Address of Agency ________________________________
________________________________
Phone # of Agency ________________________________
Fax # of Agency ________________________________
Canal General Agent Use Only
Date and Time Bound ________________________________
MVR AND CREDIT REPORT ACKNOWLEDGEMENT
I authorize Canal Insurance Company and/or Canal Indemnity to obtain a copy of any Motor Vehicle Report for
rating/underwriting the insurance for which I have applied.
DISCLOSURE: In connection with the application for commercial automobile insurance, we may review a credit report or
obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third
party in connection with the development of the insurance score. Your credit report/credit based insurance score will not
be used other than the underwriting of the commercial automobile insurance for which you have applied.
Under no circumstances can the credit-based insurance score, the lack thereof, or the refusal to authorize the obtaining of
a credit report or a credit-based insurance score is a factor in determining your eligibility for commercial automobile,
including cancellation or nonrenewal, if a policy is ultimately issued.
I authorize Canal Insurance Company and/or Canal Indemnity to obtain a credit report, including but not limited to a credit
based insurance score based on personal information provided. This authorization is valid for future reports obtained for
renewal policies with Canal.
___________________________________________ ____________________________
Applicant Signature Date
For Arkansas Applicant Only: I hereby authorize Canal Insurance Company and/or the Producing Agent to obtain from
the Arkansas Office of Driver Services a copy of my Motor Vehicle Report for the use in rating and/or underwriting the
insurance for which I do hereby apply and any renewal thereof. I understand that in obtaining a Motor Vehicle Report a
consumer reporting agency may be used by the insurer and I do hereby authorize such use. I hereby certify that the
named drivers under this policy (names specified on application and/or drivers hired during the term of this insurance)
have or will have authorized me to consent on their behalf for the insurer to obtain Motor Vehicle Reports for rating and/or
underwriting; and I hereby certify that the information above is true and agree that a misrepresentation of any of the facts
by me will constitute 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 restrictive and/or Exclusion Endorsement Text, which is included on the application and signed by me,
shall become a part of the policy.
A-101 Fleet (10-2013)
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COMMERCIAL TRUCK FLEET INSURANCE APPLICATION (Strickland Insurance Brokers)

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Completed 17 July 2021

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