Fillable Truck Application sical Damage Only) (Phy 1.Name of (Risk Placement Services, Inc.)

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Truck Application sical Damage Only) (Phy 1.Name of (Risk Placement Services, Inc.)

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  • 15 check-boxes
  • 247 other fields

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Truck Application
(Phy
sical Damage Only)
Policy Term From: To:
1.Name of Applicant
2. Address of Applicant
(Number) (Street) (City) (County) (State) (Zip Code)
3. Applicant is: G Individual G Partnership G Corporation
4. Applicant=s business to be covered?
Years experience in this business?
5. Date coverage to be effective
6. Person to contact for inspection (name and phone number)
7. Is this a new operation? G Yes G No Is your operation currently for sale? G Yes G No Seasonal in nature? G Yes G No
8. Give estimate of financial worth $
Gross receipts last year? Estimate for coming year?
9. Have you filed for Bankruptcy within the last 5 years or do you contemplate doing so? G Yes G No If yes, provide details:
DESCRIPTION AND AREA OF OPERATIONS
10. Define normal areas of operations:
11. Maximum radius operated by all trucks? G 50 G 51-200 G Over 200 Do you haul for hire? G Yes G No
12. List kinds and types of cargo hauled:
13. Do you haul any hazardous or extra hazardous substances or materials as defined by EPA? G Yes G No
If yes, what type(s) materials is being hauled? (give complete listings, naming material(s) and/or chemical content):
14. Do you pull double trailers? G Yes G No Triple trailers? G Yes G No
15. Number of vehicles owned and/or leased: Pick-Ups
Trucks Tractors Semi-Trailers Trailers Dollies
PREVIOUS INSURANCE CARRIER AND LOSS EXPERIENCE
16. Provide prior insurance carriers information for past full three years. List in order with most recent carrier first.
Policy Term Premium
Total Amount Claims Paid &
Reserves
From To
Insurance Company Name Policy Number
Number
of Motor
Powered
Vehicles
Number
of
Accidents
Physical
Damage Collision
Specified Causes
of Loss
/ / / /
/ / / /
/ / / /
17. Have you ever been declined, cancelled or nonrenewed for this kind of insurance? G Yes G No If yes, date and why
DRIVER INFORMATION
18. Does any driver listed have any convictions such as DWI/DUI of alcohol or drugs, license suspensions for moving violations, felonies, hit and run,
eluding an officer, reckless/negligent operation of a vehicle, driving while under suspension or revocation or other violations not listed above?
G Yes G No If yes, describe (including dates)
19. Driver=s pay scale is (check all that apply): G Union G Non-Union G Hourly G Trip G Mileage
G Other, explain:
20. Are you familiar with the U.S. Dept. Of Transportation driver regulations?G Yes G No Are you complying with regulations?G Yes G No
21. SCHEDULE OF ALL DRIVERS NOW EMPLOYED (If not enough space, attach separate listing)
Driver's Name
Date of
Birth Driver License No.
State
Where
Licensed
Years
Experience
Driving
Trucks
Date of
Hire
Married
(Y or N)
List All
Violations/
Convictions in
Past 5 Years
List All Accidents
in Past 3 Years
M-5547 VA (12/2010) Truck Application Physical Damage Only Page 1 of 2
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
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND
DENIAL OF INSURANCE BENEFITS.
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 VA (12/2010) Truck Application Physical Damage Only Page 2 of 2
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Truck Application sical Damage Only) (Phy 1.Name of (Risk Placement Services, Inc.)

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Completed 23 November 2020

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