Acceptance Indemnity Insurance Company
Acceptance Casualty Insurance Company
Occidental Fire & Casualty of North Carolina
Wilshire Insurance Company
Harco National Insurance Company
Transguard Insurance Company of America
RISK BOUND? YES NO DATE BOUND
TIME BOUND BROKER
INT.
EXCESS LIABILITY
SUPPLEMENTAL APPLICATION
(MUST accompany Commercial Auto Application)
1. Name of applicant:
DBA:
2. Name
of expiring Primary Carrier:
Annual Premium $
3. Limits carried by Primary Carrier:
$
Each Person $ Each Accident BODILY INJURY LIABILITY
$
Each Accident PROPERTY DAMAGE LIABILITY
4. Effective and expiration date of Primary Carrier’s Policy:
Effective Date:
Expiration Date:
5. Primary
Carrier’s Policy Number:
6. IMPORTANT: Attach a
photostat or copy of Primary Policy or daily report.
REQUESTED COVERAGE:
1. Limits of Insurance requested: .
2. Bodily Injury:
Each Person excess of Each Person
Each Accident excess of Each Accident
Premium:
Property
Damage:
Each Accident excess of Each Accident
Premium:
T
otal:
3. Give breakdown and details on Primary Carrier’s rating basis:
Bodily Injury
Property Damage
ADDITIONAL INFORMATION:
Describe all accidents for the Insured for the past 3 years:
DATE DRIVER COMPLETE DETAILS INCLUDING AMOUNTS PAID BY YOUR INSUROR
Any per
son who knowingly and with intent to defraud any insurance company or other persons files an application for
insurance containing any false information or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime.
