Fillable Commercial Automobile/Truckers Renewal Application (Colonial General Insurance Agency, Inc)

Fill Online, Printable, Fillable, Blank Commercial Automobile/Truckers Renewal Application (Colonial General Insurance Agency, Inc) Form

Use Fill to complete blank online COLONIAL GENERAL INSURANCE AGENCY, INC pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Commercial Automobile/Truckers Renewal Application (Colonial General Insurance Agency, Inc)

On average this form takes 64 minutes to complete

The Commercial Automobile/Truckers Renewal Application (Colonial General Insurance Agency, Inc) form is 5 pages long and contains:

  • 2 signatures
  • 35 check-boxes
  • 232 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Colonial General Insurance Agency, Inc forms online.

BROWSE COLONIAL GENERAL INSURANCE AGENCY, INC FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CA-APP-REN-1 (1-13) Page 1 of 5
Commercial Automobile/Truckers Renewal Application
Name Insured:
Expiring Policy No.:
Phone Number: ( )
FEIN/Social Security/Soundex No.:
Website:
Agent Name:
Agent No:
PROPOSED EFFECTIVE DATE:
From To
12:01 A.M., Standard Time, at the Address Shown on the Declarations.
PLEASE ANSWER ALL QUESTIONS
DESCRIPTI
ON OF OPERATIONS
1. List all changes to:
Name and address of insured:
Description of operations—commodities transported:
Area and radius of operations:
FILING IN
FORMATION
2. Are there any changes to the name, address or authority number? ...................................................................... Yes No
If yes, provide details:
3. List all states where filings are required:
FILING INFORMATION
4. Number of vehicles owned: Light Medium Heavy Extra Heavy
Tractors Trailers Private Passenger Types
5. Number of vehicles leased: Light Medium Heavy Extra Heavy
Tractors Trailers Private Passenger Types
CA-APP-REN-1 (1-13) Page 2 of 5
LIMIT AND COVERAGE INFORMATION
6. Liability: Combined Single Limits $ Split Limit: B.I. Per Person: $
B.I. Per Accident $ Property Damage: $
Liability Deductible: $1,000 Over $1,000 $ Submit to company—financials may be required.
7. Hired Auto: Cost of Hire: .......................................................................................................................................$
Hired auto coverage is subject to audit.
8. Non-owned Auto: Number of: Partners: Employees: Volunteers:
Non-owned auto coverage is subject to audit.
9. Uninsured Motorist: Rejected Limits Accepted
10. Underinsured Motorist: Rejected Limits Accepted
(Complete appropriate UM/UIM Selection/Rejection Form for Questions 9. and 10.)
11. Optional no-fault state: PIP rejected? ........................................................................................................................
Yes No
12. Mandatory no-fault state: PIP basic limits accepted? ................................................................................................
Yes No
(Complete appropriate Personal Injury Protection Selection/Rejection Form for Questions 11. and 12.)
13. Medical Payments:
Rejected Limits accepted:
14. Trailer Interchange: Limit $ Number of Trailers:
Deductibles: Comp $ SCOL $ Coll $
15. Do you understand that we may audit your records, which might result in an additional premium? ............... Yes No
VEHICLE SCHEDULE
(Attach copies of the vehicle registration for all vehicles and explain if registration name is different from applicant’s name.)
Vehicle No.: Year
: V.I.N.:
Make/model/type of vehicle:
ACV ST AMT: $ Value of perm. attached equip.: $
Mfg. seating capacity: Radius: Farthest city:
City, state, zip where garaged:
License state: License plate No.:
GVW/GCW: Class.:
Deductibles COMP SCOL COLL
Commercial Retail Service
Leased Vehicle? ...............................................................................................................................................................
Yes No
Loss payee/additional insured/lessor:
If limousine, name of coach builder: Length:
CA-APP-REN-1 (1-13) Page 3 of 5
Vehicle No.: Year: V.I.N.:
Make/model/type of vehicle:
ACV ST AMT: $ Value of perm. attached equip.: $
Mfg. seating capacity: Radius: Farthest city:
City, state, zip where garaged:
License state: License plate No.:
GVW/GCW: Class.:
Deductibles COMP SCOL COLL
Commercial Retail Service
Leased Vehicle? ...............................................................................................................................................................
Yes No
Loss payee/additional insured/lessor:
If limousine, name of coach builder: Length:
Vehicle No.: Year: V.I.N.:
Make/model/type of vehicle:
ACV ST AMT: $ Value of perm. attached equip.: $
Mfg. seating capacity: Radius: Farthest city:
City, state, zip where garaged:
License state: License plate No.:
GVW/GCW: Class.:
Deductibles COMP SCOL COLL
Commercial Retail Service
Leased Vehicle? ...............................................................................................................................................................
Yes No
Loss payee/additional insured/lessor:
If limousine, name of coach builder: Length:
Vehicle No.: Year: V.I.N.:
Make/model/type of vehicle:
ACV ST AMT: $ Value of perm. attached equip.: $
Mfg. seating capacity: Radius: Farthest city:
City, state, zip where garaged:
License state: License plate No.:
GVW/GCW: Class.:
Deductibles COMP SCOL COLL
Commercial Retail Service
Leased Vehicle? ...............................................................................................................................................................
Yes No
Loss payee/additional insured/lessor:
If limousine, name of coach builder: Length:
CA-APP-REN-1 (1-13) Page 4 of 5
DRIVER INFORMATION
16. Are all drivers employees? ......................................................................................................................................... Yes No
If no, provide copy of contract.
17. List below all drivers currently employed as of the proposed effective date. If a Non-Owned auto is to be con-sidered, you
must list information for all employees currently employed by you.
Driver’s Name D/C*
Date
of
Birth
Driver’s
License No.
State
Class
of
License
No. of
Years
Driving
Similar
Vehicle
Length of
Employment
List Past Three
Years of
Accidents
& Traffic
Violations
*Designation Code: O—Owner/Officer, P—Partner, E—Employee
This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein shall be the
basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an applica-
tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties. (Not applicable to Nebraska, Oregon or Vermont).
NOTICE TO ALABAMA APPLICANTS: 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 restitu-
tion fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or infor-
mation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include impris-
onment, 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 policy holder or claimant for the purpose of defrauding or attempt-
ing to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-surer files
a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a
fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
CA-APP-REN-1 (1-13) Page 5 of 5
NOTICE TO LOUISIANA 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 MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insur-
ance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for pay-
ment 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.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an applica-
tion for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: 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 fel-
ony.
NOTICE TO 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 fines
and confinement in prison.
FRAUD WARNING (APPLICABLE IN 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 include
imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: 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 bene-
fits 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 enforce-
ment 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer.)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IMPORTANT NOTICE
As part of the underwriting procedure, a routine inquiry may be made which will provide applicable information
concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Commercial AutomobileTruckers Renewal Application (Colonial General Insurance Agency, Inc)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document