Fillable EXCESS LIABILITY FOLLOW FORM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank EXCESS LIABILITY FOLLOW FORM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) Form

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

EXCESS LIABILITY FOLLOW FORM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

On average this form takes 18 minutes to complete

The EXCESS LIABILITY FOLLOW FORM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES 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
 
EXCESS LIABILITY – FOLLOW FORM
SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENT
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years for the
Applicant’s underlying Commercial Auto policies
APPLICANT’S INFORMATION
Applicant Name:
Limits Requested: $
SECTION I – UNDERLYING INSURANCE
List all Auto and Employers Liability policies to be covered as Underlying Insurance
Type
Carrier
Policy
Number
Policy
Effective
Date
Policy
Expiration
Date
Limits
Automobile
Liability
$
Automobile
Liability
$
Employers
Liability
Each Accident:
$
Disease Each Emp:
$
Disease Policy Limit:
$
Employers
Liability
Each Accident:
$
Each Accident:
$
Disease Policy Limit:
$
SECTION II – AUTO INFORMATION
Provide an accurate breakout of the Applicant’s auto fleet
Vehicle Type
# Driven < 50 Mile Radius
# Driven 50 – 200 mile radius
# Driven > 200 mile radius
Private Passenger
Light Truck
(GVW ≤10,000 lbs.)
Medium Truck
(GVW ≤ 20,000 lbs.)
Heavy Truck
(GVW 20,001 to 45,000 lbs.)
X-Heavy Truck
(GVW ≥ 45,001 lbs.)
Truck Tractors – Heavy
(GVW ≤ 45,000 lbs.)
Truck Tractors – X-Heavy
(GVW ≥ 45,001 lbs.)
Other:
$
E-PAC Follow-Form Excess
Page 1 of 2
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
1.
Does the Applicant have an auto safety & driver training program, and regular checks of MVRs?
Yes
No
2.
Does the Applicant have a vehicle maintenance program in place?
Yes
No
3.
Do the Applicant’s vehicles operate in metropolitan areas with populations of 1,000,000 or more?
Yes
No
SECTION III - EXCLUSIONS
1.
Are any underlying coverages specifically excluded or sub-limited on the Applicant’s Excess policy?
Yes
No
If yes, please describe:
SECTION IV - CLAIMS
1.
Has any underlying policy had a loss over $10,000?
Yes
No
If yes, provide details regarding claimant, nature of claim, amount paid or estimated, and final
disposition or current status.
This application is to be used in conjunction with a completed E-PAC Primary Application
.
The Undersigned states that he/she is an
authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that
the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be
relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to the effective
date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or
binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
_________________________________________________
APPLICANT: (Signature of Owner or Officer of Corporation)
Date
APPLICANT: (Print/Type Name and Title)
E-PAC Follow-Form Excess
Page 2 of 2
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
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

EXCESS LIABILITY FOLLOW FORM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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 7 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document