Fillable Form 1.: MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION

Fill Online, Printable, Fillable, Blank Form 1.: MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION Form

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

Form 1.: MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION

On average this form takes 48 minutes to complete

The Form 1.: MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION form is 3 pages long and contains:

  • 0 signatures
  • 10 check-boxes
  • 187 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION
1. Named Insured:
DBA:
COVERAGE DESIRED:
Business Personal Property
Theft of Money
Business Income
Included: Food Spoilage
Inland Marine * (MOBILE CATERING COVERAGE FORM, CMA-100)
$5,000 $10,000 $15,000
$5,000
$1,000
$10,000
$5,000
$1,000
$10,000
$5,000
$1,000
$10,000
*Inland Marine coverage only available when written with General Liability Coverage Part as a package.
INDICATE PROJECTED ANNUAL RECEIPTS $
Description of Operations: Enter "X" in Applicable Box
Type of Operations:
Type of Food Served:
Do you sell Alcohol or Tobacco Products?
Year Business Started:
Describe experience:
Applicant is an:
Days in Operation:
Name of Commissary:
Address of Commissary:
Is or are vehicle(s) garaged at this location overnight?
If "NO", are vehicles kept at a secure location with adequate key control?
Fire Protection: (Hot Trucks Only)
Is there an automatic fire extinguishing system?
If "YES", does it protect the following? (check all that apply)
Number of Fire Extinguishers:
Compliance with State & Local Permits Requirements:
Do all the operations to be insured under this policy have valid Mobile Food Vendor Permit(s)?
Permit Number(s):
Date(s) of Last Inspection(s):
Have you ever been cited for any city, county or state health code violations?
If "YES", please explain:
Hot Truck Cold Truck Espresso Vendor Catering Food Trailer
Yes No
If less than 3 years old, # of years experience in Food Industry:
Independent Owner Operator Other (please describe):
Hours of Operation:
Phone:
Yes No
Yes No
Yes No If "NO", explain:
Cooking Surfaces Deep Fat FryerGoods
ABC Class (Combustibles-Flamables-Electrical) Class K (Oils-Grease)
Yes No
If no number, attach copy of permit.
Yes No
APA-283 (08-2012) Page 1 of 3
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
1.
2.
3.
4.
8.
(Attach completed ACORD 125 and 126)
If YES, refer to company underwriter.
Other
AUTOMOBILE INFORMATION
1.
I
s there a vehicle maintenance & safety program in operation
?
2. A
re there any "Hold Harmless" agreements?
3.
D
oes the applicant obtain MVR verification before hiring?
(Selections apply to all vehicles)
Yes No
Yes No
Yes No
UNIT NUMBER ENTER "X" IN APPLICABLE BOX AND ANSWER ALL QUESTIONS PER VEHICLE
Year:
GVW:
Check One - Mobile Unit is:
City, State, Zip where garaged or parked overnight:
Purchase Date:
Did purchase price include customized kitchen?
Cost to customize or MFG:
PROTECTION
Anti Lock Braking System:
Antitheft Devices:
For Trailers: Have you installed a Hitch - lock?
Body Type: Length:Make:
Model: V.I.N. Radius:
Owner Operated Lessor Operated Employee Operated
Purchased New or Used?
New Used
Purchase Price:
Yes No N/ A
If "NO", Kitchen customized or MFG date:
Describe what was done:
2 Wheel 4 Wheel None
Lo-Jack Tele Trac Basic Alarm - No Tracking Other:
Yes No
UNIT NUMBER ENTER "X" IN APPLICABLE BOX AND ANSWER ALL QUESTIONS PER VEHICLE
Year:
GVW:
Check One - Mobile Unit is:
City, State, Zip where garaged or parked overnight:
Purchase Date:
Did purchase price include customized kitchen?
Cost to customize or MFG:
PROTECTION
Anti Lock Braking System:
Antitheft Devices:
For Trailers: Have you installed a Hitch - lock? Yes No
Lo-Jack Tele Trac Basic Alarm - No Tracking Other:
2 Wheel 4 Wheel None
Describe what was done:
If "NO", Kitchen customized or MFG date:
N/ ANoYes
Purchase Price:
New Used
Purchased New or Used?
Employee OperatedLessor OperatedOwner Operated
Model: V.I.N. Radius:
Length:Body Type:Make:
UNIT NUMBER ENTER "X" IN APPLICABLE BOX AND ANSWER ALL QUESTIONS PER VEHICLE
Year:
GVW:
Check One - Mobile Unit is:
City, State, Zip where garaged or parked overnight:
Purchase Date:
Did purchase price include customized kitchen?
Cost to customize or MFG:
PROTECTION
Anti Lock Braking System:
Antitheft Devices:
For Trailers: Have you installed a Hitch - lock? Yes No
Lo-Jack Tele Trac Basic Alarm - No Tracking Other:
2 Wheel 4 Wheel None
Describe what was done:
If "NO", Kitchen customized or MFG date:
N/ ANoYes
Purchase Price:
New Used
Purchased New or Used?
Employee OperatedLessor OperatedOwner Operated
Model: V.I.N. Radius:
Length:Body Type:Make:
APA-283 (08-2012) Page 2 of 3
SCHEDULE
NOTE: If there are more vehicles to schedule, please complete the Supplemental Scheduled Vehicles Form.
GENERAL AUTOMOBILE INFORMATION
1.
I
s / Are vehicles ever rented to others
?
2. D
oes applicant employ drivers under
21?
3
.
A
re driving records checked and ordered on new drivers at or prior to employment?
Yes No
Yes No
Yes No
DRIVER INFORMATION
If "YES", Explain:
Driver # Name Including Address Date of Birth Drivers License # State Licensed
READ AND SIGN BELOW
APPLICATION MUST BE FULLY COMPLETED AND SIGNED PRIOR TO COVERAGE BEING BOUND.
PRODUCERS SIGNATURE PRODUCERS NAME (Please Print)
APPLICANTS SIGNATURE DATE
APA-283 (08-2012) Page 3 of 3
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU. INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED
FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL
AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY
INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT
YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 SUBJECTS THE PERSON TO CRIMINAL AND (NY SUBSTANTIAL)
CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT; In DC, LA, ME, TN VA and WA, Insurance benefits may also be denied)
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE , DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANY
APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/ SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE SCHEDULED VEHICLES AND EMPLOYEES WHO DRIVE
THESE VEHICLES OR OWN VEHICLES ON COMPANY BUSINESS.
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

Form 1.: MOBILE FOOD TRUCK SUPPLEMENTAL APPLICATION

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 1 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document