Fillable Food Delivery Application 11 17 (Colonial General Insurance Agency, Inc)

Fill Online, Printable, Fillable, Blank Food Delivery Application 11 17 (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.

Food Delivery Application 11 17 (Colonial General Insurance Agency, Inc)

On average this form takes 28 minutes to complete

The Food Delivery Application 11 17 (Colonial General Insurance Agency, Inc) form is 2 pages long and contains:

  • 1 signature
  • 22 check-boxes
  • 98 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
 
Page 1 of 2 IPC-APP 01 (11/17)
FOOD DELIVERY AUTO INSURANCE
APPLICATION
Agent:
Expiration Date:
A.
GENERAL
Applicant’s Name:
Contact Person:
Mailing Address:
Zip:
Are you:
Independent or
a Franchisee
Franchise Name:
Applicant:
Individual
Partnership
Proposed Effective Date:
Corporation
Other
Years’ operating in your current business name:
Number of years your business has done deliveries
Have you owned a similar business or had any change in ownership, management or name of your current business
during the past 5 years? Yes No If yes, please explain:
Is your business a subsidiary of another entity or does your business have any subsidiaries?
Yes
No
If yes, provide details:
Total number of locations:
Total number of locations with delivery:
Do you want coverage for non-delivery locations?
Yes
No
What are the operations for non-delivery locations?
List complete addresses for all stores to be scheduled on the policy:
B.
COVERAGES REQUESTED
Hired and Non-Owned Liability Limits:
$100,000 $300,000 $500,000
$1,000,000 $1,500,000 $2,000,000
Excess Auto Liability
(Available only if you have underlying non-owned and hired auto coverage with a
different A rated carrier.)
Do you want excess coverage for Owned autos?
Yes No
If so, how many autos do you own?
Name of the primary insurance company:
Limit of Liability afforded on the primary policy:
What excess limit would you like?
($1,500,000 maximum available)
C.
OPERATIONS
1.
Product Delivered: Pizza
Asian Food
Food Courier:
Subs/Sandwiches:
Other:
2.
Number of Drivers (Employed and Contracted)
Page 2 of 2 IPC-APP 01 (11/17)
3.
Operations History
Dates
Total Annual
Receipts
Total Annual Receipts
From Food Deliveries
Total Number Of
Deliveries Annually
Projected This Year
Most Recent Year
4.
What is the minimum age of drivers delivering food?
5.
Do all of your drivers have a minimum of two years driving experience?
6.
Do you advertise a guaranteed delivery time frame?
Yes
No
How fast?
minutes
a.
What are the consequences if it is not met?
____________________________________________
b.
Provide a copy of the advertisement.
7.
Do you charge extra for deliveries?
Yes
No
If yes, how much do you charge?
8.
Do you have a Driver Safety Program?
Yes
No
If yes, please provide a copy.
9.
Are you a food courier
(deliv er f ood of other restaurants)?
Yes No
If yes, answer the following questions:
a.
What are your gross food sales?
$
b.
What percentage of food sales do you retain? %
c.
What is your delivery fee?
$
d.
How many deliveries are made per week?
e.
How many drivers contracted and employed?
D.
PRIOR AUTO INSURANCE CARRIERS AND LOSS EXPERIENCE (Add additional sheet(s) if necessary.)
Policy
Dates
Insurance
Carrier Policy # Premium
*Total Auto
Liability Claims Cancelled or Non-Renewed? (Reason)
$
#
$
$
#
$
$
#
$
$
#
$
$
#
$
*5 Years of loss runs are required, please attach. Please also describe any loss over $25,000:
E.
AGREEM ENTS AND SIGNATURES
APPLICANT: I BELIEVE THE STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT. I UNDERSTAND THAT
THE INSURER WILL RELY ON THESE STATEMENTS IF A POLICY IS ISSUED. THIS APPLICATION ALONE DOES NOT
BIND COVERAGE.
FRAUD WARNING: 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 INFORMATIO
N OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATI ON
CONCERNING ANY FACT MATERIAL THERETO IS GUILTY OF INSURANCE FRAUD. THIS IS A CRIME AND SUBJECTS
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
(FOR NEW YORK INSUREDS: AN ACT OF INSURANCE FRAUD SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO
EXCEED $5,000 AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.)
F.
SPECIAL COVERAGE RESTRICTION
I have read the endorsement called SPECIAL RESTRICTIONS AND EXCLUSIONS and agree to its terms as a condition of
the policy being issued by the company. I understand that coverage for a claim may be denied if we do not adhere to any of
the terms of the SPECIAL RESTRICTIONS AND EXCLUSIONS endorsement.
Applicant's Signature
Producer’s Signature
Date
Date
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

Food Delivery Application 11 17 (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