Excess Auto Supplement
NATIONAL INDEMNITY COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
Po
licy Term From:
To:
This application supplement is for an excess auto policy providing additional limits of liability coverage for bodily injury,
p
roperty damage, or covered pollution cost or expense and will not provide any other types of coverage.
The excess auto policy will not provide uninsured motorists coverage, underinsured motorists coverage, no-fault
coverage, medical payments coverage, first party personal injury protection coverage, garagekeepers legal liability
coverage, physical damage coverage, auto in-tow coverage, first party property damage protection coverage or any other
coverage similar to the foregoing, regardless of whether such coverage is provided by the "Primary Insurance".
This Supplement is a part of the Application and will be relied upon by the Company as an integral part of the Application.
COVERAGE INFORMATION
Total Policy Liability Limits Requested (primary and excess combined)
W
ill the primary policy be written with one of the above listed companies?
Yes No
Do
you require coverage on the excess policy that differs from the primary policy?
Yes No
If
yes, explain _______________________________________________________________________________
Will all autos owned or operated be covered by the primary policy?
Yes No
I
f no, explain________________________________________________________________________________
Do you require all covered autos on the primary policy also to be covered autos on the excess policy?
Yes No If no, explain _________________________________________________________
_
_________________________________________________________________________________________
Primary Garaging Location(s) __________________________________________________________________
__________________________________________________________________________________________
FILING INFORMATION
Is an FHWA filing required? Yes No If yes, MC number______________________________
Common Contract Broker Do you require FHWA cargo filing? Yes
M-5555 NC (12/2010) E
xcess Auto Supplement Page 1 of 2
If you hold a broker’s license, identify name filed with FHWA, FHWA docket # and receipts from brokerage operations
If you are an interstate regulated carrier, identify your registration or base state ___________________________
Is an intrastate filing needed? Yes No If yes, show state and permit number __________________
__________________________________________________________________________________________
Show exact name and address in which permits are issued ___________________________________________
__________________________________________________________________________________________
No