COVERAGES COVERED AUTO SYMBOLS LIMITS PHYSICAL DAMAGE
COVERED
COVERAGES LIMITS DEDUCTIBLE
AUTO SYMBOLS
TRAILER INTERCHANGE
COVERAGES SYMBOL # TRAILERS # DAYS RADIUS DEDUCTIBLE
COVERED AUTO SYMBOLS
APPLICANT’S SIGNATURE DATE PRODUCER’S SIGNATURE NATIONAL PRODUCER NUMBER
BI
61 67 CSL $
EA PER
62 68 BI EACH ACCIDENT $ 62 67
LIABILITY
63 71 PROPERTY DAMAGE $ COMP / OTC 63 68 $
64 64
62 67 SCL FT LSP
SPECIFIED
63 68 F FTW $
CAUSES OF LOSS
64
62 67
COLLISION 63 68 $
64
62 64 63
TOWING
MEDICAL
EACH PERSON $ $
PAYMENTS
& LABOR
63 67 67
BI
62 66 CSL $
EA PER
UNINSURED
63 67 BI EACH ACCIDENT $
MOTORIST
64 69
COMP / OTC
BI
62 66 70
CSL $
EA PER
UNDERINSURED
63 67 69
BI EACH ACCIDENT $
SPECIFIED
MOTORIST
CAUSES OF LOSS
64 70
YES STATES
COST OF HIRE IF ANY BASIS 69
NON-TRUCKERS
COLLISION $
NO
HIRED/BORROWED
$ 70
TRUCKERS
HIRED/BORROWED
LIABILITY
YES STATES
STATES # DAYS # VEH
COST OF HIRE IF ANY BASIS
NO
$
YES STATES
HIRED
GROUP TYPE NUMBER OF
PHYSICAL
NO
NON-OWNED
EMPLOYEES
DAMAGE
AUTO
VOLUNTEERS
LIABILITY
PARTNERS COVERAGE IS: PRIMARY SECONDARY
OTHER OTHER
(64) OWNED COMMERCIAL AUTOS ONLY (67) SPECIFICALLY DESCRIBED AUTOS (70) YOUR TRAILERS IN THE POSSESSION OF
(61) ANY AUTO (65) OWNED AUTOS SUBJECT TO NO-FAULT (68) HIRED AUTOS ONLY ANOTHER TRUCKER UNDER A TRAILER
(62) OWNED AUTOS ONLY (66) OWNED AUTOS SUBJECT TO A COMPUL- (69) TRAILERS IN YOUR POSSESSION UNDER INTERCHANGE AGREEMENT
(63) OWNED PRIVATE PASS AUTOS ONLY SORY UNINSURED MOTORIST LAW A TRAILER INTERCHANGE AGREEMENT (71) NON-OWNED AUTOS ONLY
FARTH
ZONE
AS DESCRIBED IN ARIZONA REVISED STATUTE 20-2104(D), A CREDIT REPORT OR OTHER INVESTIGATIVE REPORT ABOUT YOU MAY BE REQUESTED IN
CONNECTION WITH THIS APPLICATION FOR INSURANCE. ANY INFORMATION WHICH WE HAVE OR MAY OBTAIN ABOUT YOU OR OTHER INDIVIDUALS LISTED
AS POLICYHOLDERS ON OUR POLICY WILL BE TREATED CONFIDENTIALLY. HOWEVER, THIS INFORMATION, AS WELL AS OTHER PERSONAL OR PRIVILEGED
INFORMATION SUBSEQUENTLY COLLECTED, MAY UNDER CERTAIN CIRCUMSTANCES, BE DISCLOSED WITHOUT PRIOR AUTHORIZATION TO NON-AFFILIATED
THIRD PARTIES. WE MAY ALSO SHARE SUCH INFORMATION WITH AFFILIATED COMPANIES FOR SUCH PURPOSES AS CLAIMS HANDLING, SERVICING,
UNDERWRITING AND INSURANCE MARKETING. YOU HAVE THE RIGHT TO SEE PERSONAL INFORMATION COLLECTED ABOUT YOU, AND YOU HAVE THE RIGHT
TO CORRECT ANY INFORMATION WHICH MAY BE WRONG. ALSO, PURSUANT TO ARIZONA REVISED STATUTE 20-2104(C), IF YOU ARE INTERESTED IN
OBTAINING A COMPLETE DESCRIPTION OF OUR INFORMATION PRACTICES, AND YOUR RIGHTS REGARDING INFORMATION WE COLLECT, PLEASE WRITE US
AT THE ADDRESS PROVIDED WITH YOUR POLICY.
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF
DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY
RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
MOTOR CARRIER SECTION
ENDORSEMENTS
ACORD 137 AZ (2006/04)
