Fillable Commercial Auto Brokerage Application (Risk Placement Services, Inc.)

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Commercial Auto Brokerage Application (Risk Placement Services, Inc.)

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  • 92 check-boxes
  • 420 other fields

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CC 969 03 16
CC 969 03 16 Page 1 of 9
Commercial Auto Brokerage Application
Complete the entire application and sign.
BROKERING AGENT’S REGISTER #
New Business Renewal - Expiring Policy #
Agency Name:
New Business to the Agent
Agency Renewal for Years
Proposed Effective Date:
Expiration Date:
Payment Options:
Prepaid Policy 12 Pay / Continuous Policy Quarterly Installment Premium Pay Plan Nine Installment Premium Pay Plan
Monthly Reporting - Indicate reporting basis:
Gross Receipts Mileage Power Units
Applicant Information
Applicant’s Legal Name (If more than one named insured, please attach
an explanation):
Continuous Years in Business Under
This Name:
Years of Industry
Experience:
Individual Partnership Corporation Other:
Ownership Information:
Name:
Position / Title: # Years: Percentage of Ownership:
Contact Person: Title: Phone Number:
Mailing Address (Include City, State, County, Zip):
MC #: DOT #:
Principal Garaging Address (If different from above):
Years at this location: FEIN / SSN:
Terminal Location Street Address City and State Security Measures –
Lighted (L), Fenced (F),
Security Alarm (A), Dogs (D),
Security Guards (SG)
Location Description –
Terminal (T), Maintenance (M), Office (O),
Warehouse (W)
Current ownership and senior management structure in place for at least three years? Yes No
If more than one named insured, provide details including a description of operations for each. Attach a separate page if needed:
Has the applicant operated under a different name and/or authority in the past five years? Yes No
If yes, provide details and DOT or MC number:
Is the applicant a subsidiary of another entity or does the applicant own any subsidiaries? Yes No
If yes, provide details:
Has the applicant filed for bankruptcy in the past 5 years? Yes No If yes, provide the date: Discharge date:
Has there been a change in ownership in the past 3 years? Yes No If yes, provide details:
Has the applicant’s insurance coverage been cancelled or non-renewed in the past 3 years? Yes No (Not applicable in Missouri)
If yes, please provide the date and reason:
CC 969 03 16
CC 969 03 16 Page 2 of 9
Description of Operations
Carrier Type: Common Carrier Contract Carrier Exempt Carrier Other:
Commercial Classification: Trucking For Hire Private Other:
Does the applicant haul hazardous commodities regulated by the FMCSA? Yes No
If yes, please provide a detailed description of the commodity, UN number, type and size of packaging, and type of trailer used:
Are you under a permanent lease agreement? Yes No If yes, provide name and DOT or MC number:
Loads transported are: Truckload Less than truckload (LTL) If LTL, please include the percentage: %
Percentage of loads secured through: Freight Brokers % Contracts with Shippers % Arranged by Applicant %
Do you operate as a broker or freight forwarder? Yes No If yes, under what name?
MC # Are trailers owned by the applicant used in the brokerage operation? Yes No
Is All equipment owned by you, operated by you, under your authority or leased to you? Yes No
If no, please provide an explanation:
Are containers transported? Yes No If yes, percentage: %
Do you pull doubles or triples? Yes No If yes, check: Doubles % Triples %
Do you own auxiliary power units? Yes No (If yes, be sure to include value in total equipment value.)
Are oversize/overweight loads transported? Yes No If yes, please complete the following:
Percentage of total loads: % Are escorts required? Yes No
Minimum required years of experience for assigned drivers:
Are special permits required other than OS-32? Yes No If yes, please provide details in the Comments section.
Does the insured perform maintenance, mechanical repairs or body work on the trucks or trailers of others? Yes No
Drivers are compensated: Hourly Miles Trip % of revenue Average annual driver salary:
Are team drivers used? Yes No Slip seat? Yes No
Do drivers get home each week? Yes No
Percentage of dedicated or established routes to the same destinations: %
Percentage of annual trips: 0-50 miles % 51-200 miles % 201-500 miles % 501-1000 miles % Unlimited %
Average radius of operation: Maximum radius of operation: Percentage of miles over 500 miles radius: %
Describe the primary routes traveled (i.e. Charlotte, NC to York, PA) and provide an estimate of the percentage of total hauls for each:
City, State: to % City, State: to %
City, State: to % City, State: to %
City, State: to % City, State: to %
Check the metropolitan areas traveled into or through for all operations beyond 200 miles:
Atlanta
Baltimore
Boston
Buffalo
Charlotte
Chicago
Cincinnati
Cleveland
Dallas/Ft Worth
Denver
Detroit
Hartford
Houston
Indianapolis
Jacksonville
Kansas City
Little Rock
Los Angeles
Louisville
Memphis
Miami
Milwaukee
Minn/ St. Paul
Nashville
New Orleans
New York City
Oklahoma City
Omaha
Philadelphia
Phoenix
Pittsburgh
Portland
Richmond
St. Louis
Salt Lake City
San Diego
San Francisco
Seattle
Tulsa
Washington DC
Other:
CC 969 03 16
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Driver Information
(Attach a list of all company and owner operator drivers and include the following information:
Driver’s Name as
listed on license
Date of
Birth
CDL
State
CDL
Number
Years Licensed
with CDL
# Years Driving
Similar Equipment
Date
of Hire
# of
Accidents
Driver Hiring:
Minimum Age: Minimum years experience driving similar equipment:
Maximum number of minor violations in the prior 3 years: Maximum number of minor violations in the prior 12 months:
Maximum number of accidents in the prior 3 years: Describe major violations in the prior 3 years considered unacceptable :
Over the last 36 months have any of your drivers been involved in an accident resulting in a fatality? Yes No If yes, provide date(s)
and details of loss.
Loss Control & Safety Management
Loss Control / Safety Manager:
Years employed in current
position:
Years of similar experience:
Percentage of time dedicated
to safety: %
Is a formal written loss control program in place and being used? Yes No If yes, please attach a copy of the formal safety
manual, driver’s handbook and driver hiring guidelines, if applicable.
How many times during the year are driver safety meetings held? Are drivers required to attend? Yes No
Is an accident investigation conducted on all losses by the loss control manager or owner? Yes No
Are accident reviews conducted with the driver including corrective or disciplinary action if needed? Yes No
Are MVRs ordered and previous employment verified prior to hiring a driver? Yes No
Have you registered for PSP to assist with pre-employment screening of all drivers? Yes No
Are written minimum hiring standards including years experience and MVR requirements in place and being used? Yes
No
If yes, please attach a copy.
Is a formal driver disciplinary policy in place and being used? Yes No If yes, please attach a copy.
Is written scheduled maintenance required for all vehicles? Yes No
Is a formal written maintenance program in place and being used? Yes No
Are drivers required to complete pre-trip inspections? Yes No
Do you perform any repairs or maintenance on your vehicles including trailers? Yes No
If yes, list the types of repairs and maintenance performed:
Include the name and location of the repair shop used for all other repairs and maintenance:
Total number of full time mechanics:
Number that are certified:
Number of master mechanics:
Is work performed on non-owned vehicles? Yes No
If yes, please provide details including total revenue generated and types of work performed.
Are you operating your power units with speed governors? Yes No If yes, what is the set speed?
Are power units equipped with fender mirrors? Yes No
Are power units equipped with alarms? Yes No Are trailers equipped with alarms? Yes No
Are trailers left loaded overnight away from the described terminal(s)? Yes No If yes, please provide details:
Are non-employee passengers allowed? Yes No If yes, is passenger accident coverage in place? Yes No
Does your safety program include driving incentive/safety awards? Yes No
If yes, please describe:
Does your safety program include incentives for violation free inspections? Yes No
If yes, please describe:
Do your driver and equipment files conform to DOT requirements? Yes No
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Are road tests required for all prospective drivers? Yes No Is the safety manager required to conduct these tests? Yes No
Are power units equipped with on-board computers? Yes No
Are power units equipped with electronic on-board recorders? Yes No
Are power units equipped with electronic log programs used to audit driver log books? Yes No
Are power units equipped with GPS tracking systems? Yes No
Are trailers equipped with GPS tracking systems? Yes No
Do you use road observation services (e.g. 1-800, Driver Check, etc.) or electronic monitoring (e.g. Nextel, PeopleNet, etc.)? Yes No
Describe:
Do you utilize dashboard cameras? Yes No
Are you involved in a drug/alcohol testing program? Yes No
Percentage of owner operators used? % If used, please answer each of the following questions:
Are owner operators required to adhere to the same maintenance program as owned equipment? Yes No
Is the equipment inspected by the insured? Yes No How often?
Are equipment files maintained by the insured? Yes No
Are driver files maintained by the insured? Yes No
Are permanent and exclusive lease agreements used? Yes No If yes, please attach a copy.
Are trip lease agreements used? Yes No
Does the applicant report all owner operator miles and are they included on the fuel tax reports provided? Yes No
Do you use subhaulers? Yes No What is total cost of hire? (Provide a copy of the subhaul agreement.)
Coverages (Select all that apply)
Auto Liability Coverage Combined Single Limit: Deductible: $
Uninsured Motorists Limit (CSL): Underinsured Motorists Limit (If rated separately):
Personal Injury Protection (PIP) Limit: Medical Payments Limit Per Person:
Are all drivers covered by Workers Compensation? Yes No If yes, provide carrier’s name and policy number.
Physical Damage (Attach an equipment schedule with actual cash values) Deductibles: Comprehensive: $ Collision: $
SCOL: $
Non-Owned Trailer Physical Damage Max Value: $ Maximum number of non-owned trailers in possession at any one time:
Trailer Interchange
Limit: Deductibles: Comprehensive: $ Collision: $ SCOL: $
Maximum value per trailer: Average number of non-owned trailers per day: Number of trailer days per year:
Hired Auto Liability Estimated Cost of Hire: OR Required by Contract Only
Hired Auto Physical Damage Maximum Value: Number of Days:
Non-owned Trailer Coverage Maximum Value: Number of Trailers:
Non-Owned Liability Number of Employees:
Drive Other Car Driver Name(s):
Cargo Limit: Deductible: $ (Complete and attach Cargo Supplemental Application)
General Liability Limit: (Complete and attach Supplemental Application for General Liability Coverage)
Basket Deductible: $
CC 969 03 16
CC 969 03 16 Page 5 of 9
Equipment
TYPE
(Attach a complete vehicle
schedule including GVW for all
straight trucks.)
Company Owned Long Term Leased Without
Driver
Permanently Leased With Driver
(Owner Operated)
Tractors
Trucks
Light Service
Private Passenger
Dry Van Trailers
Refrigerated Trailers
Flatbed Trailers
Bottom Dump or Hopper Trailers
End Dump Trailers
Tank Trailers
Other Trailer Types
Total Insured Value – Power Units: Total Insured Value – Trailers:
Exposure History
Year Revenue Mileage
Fuel tax reports are required for
each of the past four quarters.
Number of Power
Units
Fleet Total Insured Value
Projected
Expiring
1
st
Prior
2
nd
Prior
3
rd
Prior
Average annual miles per revenue unit: Average annual gross revenue per revenue unit:
Loss Experience
Complete the following Summary and attach currently valued company loss runs. A minimum of four years of experience is required
(Five years preferred).
Policy Period Number of Occurrences Total Incurred (paid, reserve & expense)
From To Liability Phys Dam Cargo Gen Liab Liability Phys Dam Cargo Gen Liab
Describe all losses in excess of $ 50,000. Please include the driver’s name and date of loss:
List the current deductible amount for each line of coverage:
Auto Liability: Physical Damage: Cargo: General Liability:
CC 969 03 16
CC 969 03 16 Page 6 of 9
COMMENTS:
NOTICE TO ARIZONA APPLICANTS: AS DESCRIBED IN ARIZONA REVISED STATUTE 20-2104(D), A CREDIT REPORT OR OTHER
INVESTIGATIVE REPORT ABOUT YOU MAY BE REQUESTED IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. ANY
INFORMATION WHICH WE HAVE OR MAY OBTAIN ABOUT YOU OR OTHER INDIVIDUALS LISTED AS POLICYHOLDERS ON OUR POLICY
WILL BE TREATED CONFIDENTIALLY. HOWEVER, THIS INFORMATION, AS WELL AS OTHER PERSONAL OR PRIVILEGED INFORMATION
SUBSEQUENTLY COLLECTED, MAY UNDER CERTAIN CIRCUMSTANCES, BE DISCLOSED WITHOUT PRIOR AUTHORIZATION TO NON-
AFFILIATED THIRD PARTIES. WE MAY ALSO SHARE SUCH INFORMATION WITH AFFILIATED COMPANIES FOR SUCH PURPOSES AS
CLAIMS HANDLING, SERVICING, UNDERWRITING AND INSURANCE MARKETING. YOU HAVE THE RIGHT TO SEE PERSONAL
INFORMATION COLLECTED ABOUT YOU, AND YOU HAVE THE RIGHT TO CORRECT ANY INFORMATION WHICH MAY BE WRONG. ALSO,
PURSUANT TO ARIZONA REVISED STATUTE 20-2104(C), IF YOU ARE INTERESTED IN OBTAINING A COMPLETE DESCRIPTION OF OUR
INFORMATION PRACTICES, AND YOUR RIGHTS REGARDING INFORMATION WE COLLECT, PLEASE WRITE US AT THE ADDRESS
PROVIDED WITH YOUR POLICY.
NOTICE TO ARKANSAS APPLICANTS: 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.
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.
I understand this application is not a binder unless indicated as such on this form by the
brokering agent.
Applicant’s Signature
Date Application Completed
BROKERING
AGENT’S
REGISTER #
This application is in compliance with Section 626.752, Florida Statutes. A copy has been
furnished to the applicant or insured and coverage is
Bound effective
(time)
(date);
Not Bound
Binder must be approved by Authorized Licensed Representative of Carolina
Casualty/Great Divide Insurance Company.
Signature of Producing Agent
Date Application Completed
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.
APPLICABLE TO BUSINESS AUTO, TRUCKERS AND MOTOR CARRIER: IS/ARE GARAGING LOCATION(S) WITHIN CITY LIMITS?
YES ______ NO ______ IF NO, PROVIDE NAME(S) OF APPLICABLE TAX TERRITORIES: _______________________________________
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CC 969 03 16
CC 969 03 16 Page 7 of 9
NOTICE TO MAINE, TENNESSEE, VIRGINIA & WASHINGTON 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 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
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 JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW MEXICO AND RHODE ISLAND APPLICANTS: 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.
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 OKLAHOMA APPLICANTS: 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.
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.
“REPRESENTATIVE OF THE CONSUMER” (APPLICANT)
I ACKNOWLEDGE THAT MY RETAIL BROKER/PRODUCER IS NOT APPOINTED BY CAROLINA CASUALTY/GREAT DIVIDE INSURANCE
COMPANY (“CCI/GDI”) AND IS ACTING AS MY REPRESENTATIVE, AUTHORIZED TO PRESENT THIS APPLICATION ON MY BEHALF TO A
CONTRACTED AND APPOINTED GENERAL AGENT OF “CCI/GDI”. I UNDERSTAND THAT IN THIS CAPACITY MY BROKER/PRODUCER HAS
NO UNDERWRITING OR BINDING AUTHORITY WITH “CCI/GDI” AND CAN NOT BIND COVERAGE OR MODIFY THIS APPLICATION OR ANY
SUBSEQUENT “CCI/GDI” POLICY. ANY BINDER OR POLICY MODIFICATION WILL BE VALID ONLY IF ISSUED BY A CONTRACTED AND
APPOINTED GENERAL AGENT OR OTHER AUTHORIZED COMPANY REPRESENTATIVE OR EMPLOYEE OF “CCI/GDI”. I FURTHER
ACKNOWLEDGE THAT MY BROKER/PRODUCER FEE FOR THIS SERVICE IS $ ____ (ABSENCE OF ENTRY MEANS NONE).
Signature of Broker/Producer
Signature of Applicant
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.
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NOTICE TO NEW HAMPSHIRE APPLICANTS:
STATEMENT OF RESIDENCY INCLUDING APPLICABLE EXEMPTIONS
(a)
A resident is a person who maintains his or her true, fixed and permanent residence within the State of New
Hampshire, does not claim residency in any other state for any purpose and who has, through all of his or her
actions, demonstrated a current intent to designate that the permanent residence is his or her principal place of
physical presence for the indefinite future to the exclusion of all others; or
(b) A resident is a person who has previously met the conditions of (a) above and who now maintains a permanent
residence in New Hampshire for the entire year and has actually spent more than 183 days in New Hampshir
e
dur
ing the previous calendar year; or
(c
)
A resident is a person who is without a permanent street address due to homelessness, or, a person who is
temporarily without a permanent street address due to traveling outside of the state of New Hampshire in
a
recreational vehicle for a period not to exceed 2 years, and who has met and can demonstrate the requirements of
RSA 261:52-b or RSA 261:52-c.
(d) Exemption from residency may be claimed if:
(1) The motor vehicle to be insured is garaged exclusively in New Hampshire; or
(2) The individual is on active duty in the military service of the United States and claims New Hampshire as their
legal state of residence; or
(3) The individual is on active duty in the military service of the United States, currently stationed in New
Hampshire, and all vehicles to be insured on this policy are currently garaged in New Hampshire.
(e) I understand that if I falsely claim for myself or any named insured to be a resident of the State of New Hampshire,
or if I claim for myself or any named insured to be entitled to exemption hereunder, I am subject to prosecution,
imprisonment of up to one year, a fine of $2,000 and the denial of coverage for any loss, not occurring in New
Hampshire, under the automobile insurance policy for which I am applying.
(f) I also understand that this statement will be relied upon in connection with future renewals of the automobil
e
i
nsurance policy for which I am applying, and that it is my responsibility to inform my insurance company befor
e
m
y next renewal after I or any named insured ceases to be a New Hampshire resident and that I will be subject t
o
t
he penalties listed in (d) above if I fail to do so.
(g) I/we, the applicant(s), has/have read the above and understand the penalties that may apply if I/we falsely claim t
o
be a
New Hampshire resident, or if we claim to be entitled to exemption hereunder.
CHECK ONE:
I hereby attest that I am, and each named insured is, a resident of the State of New Hampshire as defined in (a)
and (b) above and that I maintain a permanent residence located at:
New Hampshire
Street Address:
City
(Zip)
or that I, and each named insured, has met and can demonstrate the requirements of RSA 261:52-b or RSA 261:52-c
as defined in (c) above.
I hereby claim that I am, and each named insured is entitled to exemption hereunder pursuant to (d) above.
Signed at:
New Hampshire
Street Address:
City
(Zip)
NOTICE TO ILLINOIS APPLICANTS: THE RELIGIOUS FREEDOM PROTECTION AND CIVIL UNION ACT (“THE ACT”) PROVIDES THAT THE
PARTIES TO A CIVIL UNION ARE ENTITLED TO THE SAME LEGAL OBLIGATIONS, RESPONSIBILITIES, PROTECTIONS AND BENEFITS
THAT ARE AFFORDED OR RECOGNIZED BY THE LAWS OF ILLINOIS TO SPOUSES. YOUR POLICY OR CONTRACT PROVIDES PARTIES
TO A CIVIL UNION AND A MARRIAGE IDENTICAL BENEFITS AND PROTECTIONS, AS REQUIRED BY THE ACT.
NOTICE TO WYOMING APPLICANTS: I UNDERSTAND THAT THE AUTOMOBILE INSURANCE THAT I AM BUYING INCLUDES AN
AMENDMENT WHICH STATES THAT IF I HAVE A LOSS TO A VEHICLE AND AM PAID FOR THAT LOSS BUT DON’T ACTUALLY REPAIR THE
VEHICLE, ANY SUBSEQUENT LOSSES WILL BE PAID WITH THE COST OF THE DAMAGE ASSOCIATED WITH PRIOR LOSSES BEING
DEDUCTED.
NOTICE TO VIRGINIA APPLICANTS: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS
APPLICATION IS BEING MADE, IF ISSUED, MAY BE CANCELED 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.
CC 969 03 16
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PRIVACY NOTIFICATION: 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.
Signatures
I understand this application is not a binder and that binding must be made by an Authorized Licensed Representative of Carolina Casualty/Great
Divide Insurance Company.
I hereby authorize Carolina Casualty/Great Divide Insurance Company and/or the Producing Agent to obtain from the proper authority a copy of my
Motor Vehicle Report and/or Credit Report for use in rating and/or underwriting the insurance for which I do hereby apply and any renewal thereof.
I hereby represent 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.
I have read this application and all of the responses are mine and not supplied by the producer, agent or company.
I HEREBY REPRESENT THAT ALL INFORMATION IN THIS APPLICATION AND ANY ATTACHMENTS THERETO ARE TRUE.
Date Application
Completed
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Of Agent
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Agent Registration #
Licensed Agent of the Company
Agent Phone Number
Licensed Agent ID#
Agent Signature
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Commercial Auto Brokerage Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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