Fillable TRUCKERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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TRUCKERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-74s (6-17) Page 1 of 5
TRUCKERS PROGRAM SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. List all offices, terminals, warehouses, garage locations or other premises the applicant owns or leases:
Loc.
No.
Complete Address
Describe Function
of Location
Payroll
(other than
drivers &
clerical)
Owned
(check if
applicable)
Leased
(% of bldg
leased)
1 $ %
2 $ %
3 $ %
4 $ %
5 $ %
2. Type of carrier: Common Carrier Contract Carrier
If contract, who does the applicant haul for?
3. Number of vehicles: Owned: Leased:
Not owned but operated on applicant’s behalf:
Are all vehicles licensed? ............................................................................................................................ Yes No
If no, explain:
4. Any oversize/overweight permits required? ........................................................................................... Yes No
If yes, explain:
5. Does applicant have any private warehouses? ...................................................................................... Yes No
If yes, area:
6. Is there an established equipment maintenance program? ................................................................. Yes No
GL-APP-74s (6-17) Page 2 of 5
7. Provide the following information for all locations:
Loc. 1 Loc. 2 Loc. 3 Loc. 4 Loc. 5
Fenced Yes No
Yes No
Yes No
Yes No
Yes No
Guard Dogs Yes No
Yes No
Yes No
Yes No
Yes No
Lighted Yes No
Yes No
Yes No
Yes No
Yes No
Public Access Yes No
Yes No
Yes No
Yes No
Yes No
Security Guards Yes No
Yes No
Yes No
Yes No
Yes No
Radius of operation
(in miles):
States applicant operates in:
Any fuel storage and/or
underground tanks?
Yes No
Yes No
Yes No
Yes No
Yes No
If yes, indicate location number and provide details:
a. Type of fuels stored:
b. Is fuel for private use or sold to others?
c. If sold to others, number of gallons sold annually:
8. Indicate operations provided by applicant:
Bicycle messenger services
Courier: What is delivered?
Crane services
Crating and uncrating
Debris removal—construction sites
Escort vehicles for oversize/overweight loads
Excavation and/or grading of land
House moving
Ice cream trucks: .......................................................................................................... Gross Sales: $
Public livery
Sand or salt dispensing on roadways: .......................................................................... Payroll: $
Sandwich/catering trucks: ............................................................................................ Gross Sales: $
Snow/ice removal: ........................................................................................................ Payroll: $
Towing with service or repair
Towing without service or repair
Truck brokering
9. Does applicant operate any mobile equipment, such as a backhoe, bobcat, bulldozer or forklift? Yes No
If yes, specify equipment operated:
10. Commodities hauled:
Asphalt Garbage/rubbish (commercial) Medical waste
Chemicals Garbage/rubbish (residential) Mobile homes
Coal Heavy/oversized loads Oil field equipment
Explosives Household furniture/goods Tires
Fertilizer Logging and lumbering products Toxic/hazardous waste
Flammable materials LPG
Fuel/oil Marijuana/cannabis or products containing marijuana/cannabis
Other; describe:
GL-APP-74s (6-17) Page 3 of 5
11. Is applicant involved in or have operations that support any type of hydraulic fracturing or
hydrofracking operations? ....................................................................................................................... Yes No
If yes, describe:
12. Does applicant do rigging? ...................................................................................................................... Yes No
If yes, provide receipts, type of equipment, and describe the types of jobs performed:
13. Other operations:
a. Use aircraft? .......................................................................................................................................... Yes No
b. Does applicant provide dumpsters for pick up? .................................................................................... Yes No
If yes, how many?
c. Own or operate a landfill or dump? ....................................................................................................... Yes No
d. Product assembly/installation? ............................................................................................................. Yes No
If yes, describe:
e. Product service/repair? ......................................................................................................................... Yes No
If yes, describe:
f. Repossession operations? .................................................................................................................... Yes No
g. Storage lots for non-owned vehicles/equipment? ................................................................................. Yes No
If yes, area:
h. Other, describe:
14. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work:
c. Are all subcontractors required to carry General Liability insurance? .................................................. Yes No
If yes, minimum General Liability limits required:
d. Are all subcontractors required to carry Workers Compensation insurance? ...................................... Yes No
e. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
f. Is applicant included as additional insured on all subcontractors’ policies? ......................................... Yes No
g. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
15. Other Insurance Information:
Auto Liability Motor Truck Cargo
Policy Number
Insurance Carrier
Limits of Liability
Expiration Date
16. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GL-APP-74s (6-17) Page 4 of 5
17. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
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 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 such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
GL-APP-74s (6-17) Page 5 of 5
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE 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 information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email:
Preferred Method of Correspondence Email Fax Mail
Applicant Email:
Preferred Method of Correspondence Email Fax Mail
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TRUCKERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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