D. Auto Liability Information q Not Applicable
Is hired and non-owned auto provided by the underlying? q Yes q No
Are any drivers under 21 years of age? q Yes q No
Does any vehicle travel an average daily radius greater than 200 miles? q Yes q No
Does risk own any heavy trucks, extra heavy trucks or truck tractors, livery units or tow trucks? q Yes q No
Are any vehicles authorized to transport any of the following? q Yes q No
– Corrosive, explosive, flammable (i.e. fuel), or radioactive materials?
– Any type of refuse, waste or trash (including recyclables)?
– Livestock?
Are motor vehicle records reviewed for acceptability at least once every three years? q No q Yes
For any driver over the age of 69, is a Statement of Fitness required to be signed by a physician? q No q Yes
Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements
set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The
undersigned further declares that any claim, incident or event taking place prior to the effective date of insurance applied for which may render
inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw
or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind
the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the
Company is relying on the Application in the event the Policy is issued. It is agreed that this Application, including any material submitted
therewith, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Colorado Fraud Statement: 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 from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Fraud Statement: 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 Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: 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.
Maine Fraud Statement: 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 a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: 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 shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Fraud Statement: 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 Fraud Statement: 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.
Number Type A Units
Private Passenger
Light Trucks (up to 10,000 GVW)
Medium Trucks (10,001 - 20,000)
CUA 9/08
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