22. SCHEDULE OF AUTOS/VEHICLES TO BE COVERED
Auto/
Vehicle
No.
Year
Model Trade Name
Body Type
PP Auto, Pick-Up,
Truck, Tractor,
Semi-Trailer,
Trailer, Cargo Van
Serial No. (S)
Vehicle ID No. (VIN)
Maximum
Gross
Weight of
Vehicle
and Load
(lbs.)
Estimated
Annual
Mileage
Anti-Lock
Brakes (A),
Airbags (B)
or Anti-Theft
Devices (C)
Use*
S) Service
R) Retail
C) Comm
B) Bus. Use PP
Size
GVW,
GCW
of Vehicle
Maximum
Radius of
Operations
(miles)
1
2
3
4
5
*Vehicle Use: S) Service B Transportation of Personnel, Tools, and C) Commercial B All other.
Equipment and usually parked at job site
. B) Private Passenger Vehicles Used in business.
R) Retail
B House to house delivery.
23. PHYSICAL DAMAGE COVERAGES DESIRED (complete spaces below in detail for each respective auto/vehicle described above.)
Specified Causes of Loss Collision
Auto/
Vehicle
No.
Town & State Where
Principally Garaged
Original
Cost New
of Chassis,
Body &
Equipment
Date
Purchased
Mo/Yr
Purchased
New (N)
Used (U)
Cost When
Purchased
Value of
Vehicle
Excluding
Permanently
Attached
Special
Equipment
Value of
Permanently
Attached
Special
Equipment
Amount of
Insurance Deductible
Amount of
Insurance Deductible
1
2
3
4
5
24. Any loss payees? G Yes G No If yes, indicate for which vehicle(s) and give name and address of loss payees:
MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the policy
effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is acting as
Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may not accept any
funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false, the
Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be attached to
the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any
other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background
information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be
provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
Will premium be financed? Yes No If yes, with whom
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.
Witness Applicant's Signature Date
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE
Is this direct business to your office?
If not, explain
Is this new business to your office? If not, how long have you had the account?
How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Please quote Please bind at earliest possible date and issue policy
Please issue policy effective
Coverage was bound by
(Time and Date Bound by General Agent) (Name of Person in Company General Agency's Office Binding Coverage)
Applicant's Representative's Name and Address Phone No.
M-5547 MD (12/2010) Truck Application Physical Damage Only Page 2 of 2
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