22. SCHEDULE OF AUTOS/VEHICLES TO BE COVERED
Auto/
Vehicle
No.
Model
Year Trade Name Body Type
Serial No. (S)
Vehicle ID No. (VIN)
Original
Mfg.
Seating
Capacity
Limos B
Length of
Stretch
To 60" (A)
Over 60" (B)
Over 102"
(C)
Principal
Garaging
Location
Radius of
Operation
(miles)
Estimated
Annual
Mileage
Per
Vehicle
Anti-Lock
Brakes (A),
Air Bags (B),
Lifts (C),
or Other
Handicapped
Equipment
(D)
1
2
3
4
5
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.
Original Cost
New of
Chassis,
Body & Equip.
Date
Purchased
Mo/Yr
Purchased
New (N)
Used (U)
Cost When
Purchased Present Value
Amount of
Insurance
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
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-5546 (12/2010) Public Auto Application Physical Damage Only Page 2 of 2
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signature
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