BUSINESS AUTO SECTION

    AGENCY CUSTOMER ID:

    DATE (MM/DD/YYYY):

    AGENCY:

    CARRIER:

    NAIC CODE:

    POLICY NUMBER:

    EFFECTIVE DATE:

    NAMED INSURED(S):

    DRIVER INFORMATION

    ACORD 163 attached for additional drivers

    Driver #

    Name

    City, State, Zip

    Sex

    Mar Stat

    Date of Birth

    Yrs Exp

    Year Lic

    DL #

    SSN

    State Lic

    Date Hire

    Broken/No Fault

    Doc

    Veh #

    % Use

    * MARITAL STATUS / CIVIL UNION (if applicable)

    GENERAL INFORMATION

    1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?

    VEH # NAME OF OTHER OWNER

    VEH # NAME OF OTHER OWNER

    2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS?

    3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?

    4. ARE ANY VEHICLES LEASED TO OTHERS?

    5. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups)

    VEH # DESCRIPTION COST $

    VEH # DESCRIPTION COST $

    6. ARE ICC (Interstate Commerce Commission), PUC (Public Utility Commission) OR OTHER FILINGS REQUIRED?

    7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?

    8. ANY HOLD HARMLESS AGREEMENTS?

    9. ANY VEHICLES USED BY FAMILY MEMBERS? IF SO, IDENTIFY.

    10. DOES THE APPLICANT OBTAIN MVR (Motor Vehicle Record) VERIFICATIONS?

    11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD?

    12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION?

    13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION?

    14. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?

    Applicable only in Kansas: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO INSURERS:

    1. A speeding violation of up to six (6) mph in an area with a posted speed limit from 30–54 mph

    2. A speeding violation of up to ten (10) mph in an area with a posted speed limit from 55–75 mph

    DRV # DATE (MM/DD/YYYY) TYPE

    PLACE (City, State) # YRS REV

    15. HAS AGENT INSPECTED VEHICLES?

    16. ARE ALL VEHICLES TO BE INCLUDED IN THIS POLICY PART OF A FLEET?

    17. DO YOU HAVE ELECTRONIC MONITORING DEVICES THAT RECORD AND TRANSMIT DATA IN ANY OF YOUR VEHICLES?

    If "YES", what percentage of vehicles in your overall fleet are monitored (1 - 100%)

    %

    Please indicate how you utilize the devices (check all that apply):

    Monitor Driver SafetyTrack Fuel ConsumptionMonitor Vehicle MaintenanceMileage TrackingLocation TrackingNavigation

    Describe:

    DESCRIPTION OF GARAGE / STORAGE LOCATIONS

    MAXIMUM DOLLAR VALUE SUBJECT TO LOSS

    $

    ADDITIONAL INTEREST / CERTIFICATE RECIPIENT – ACORD 45 attached for additional names

    INTEREST

    Additional InsuredEmployee As LessorLender's Loss PayableLienholder

    Loss PayeeOwnerRegistrant

    INTEREST IN ITEM NUMBER

    VEHICLE:

    LOCATION:

    NAME AND ADDRESS:

    RANK:

    EVIDENCE: Evidence
    CERTIFICATE: Certificate

    REFERENCE / LOAN #:

    INTEREST

    Additional InsuredEmployee As LessorLender's Loss PayableLienholder

    Loss PayeeOwnerRegistrant

    INTEREST IN ITEM NUMBER

    VEHICLE:

    LOCATION:

    NAME AND ADDRESS:

    RANK:

    EVIDENCE: Evidence
    CERTIFICATE: Certificate

    REFERENCE / LOAN #:


    Vehicle Description

    VEH #

    YEAR

    MAKE

    MODEL

    BODY TYPE

    V.I.N.

    VEHICLE TYPE

    Garaging Address

    STREET

    CITY

    COUNTY

    STATE

    ZIP

    LIC STATE

    TERR

    Vehicle Use & Coverage

    USE

    PLEASUREFARMCOMM'LRETAILSERVICEFOR HIRE

    GVW / GCW

    CLASS

    SIC

    FACTOR

    SEAT CP

    RADIUS

    FARTHEST TERMINAL

    COST NEW

    Drive to Work / School

    DRIVE TO WORK / SCHOOL

    Coverage Details

    CHECK COVERAGES

    LIABNO-FAULTMED PAYUNINS MOTOR

    ADD'L COVERAGES

    TOWING & LABORSPEC C OF L

    DEDUCTIBLES

    COMP/OTC:

    COLL:

    ACV/ST AMT

    TOTAL PREM

    VEH #

    YEAR

    MAKE

    MODEL

    BODY TYPE

    V.I.N.

    VEHICLE TYPE

    Garaging Address

    STREET

    CITY

    COUNTY

    STATE

    ZIP

    LIC STATE

    TERR

    Vehicle Use & Coverage

    USE

    PLEASUREFARMCOMM'LRETAILSERVICEFOR HIRE

    GVW / GCW

    CLASS

    SIC

    FACTOR

    SEAT CP

    RADIUS

    FARTHEST TERMINAL

    COST NEW

    Drive to Work / School

    DRIVE

    NET VEH DR/CR:

    Coverage Details

    CHECK COVERAGES

    LIABNO-FAULTMED PAYUNINS MOTOR

    ADD'L COVERAGES

    TOWING & LABORSPEC C OF L

    DEDUCTIBLES

    COMP/OTC:

    COLL:

    ACV/ST AMT

    TOTAL PREM

    VEH #

    YEAR

    MAKE

    MODEL

    BODY TYPE

    V.I.N.

    VEHICLE TYPE

    Garaging Address

    STREET

    CITY

    COUNTY

    STATE

    ZIP

    LIC STATE

    TERR

    Vehicle Use & Coverage

    USE

    PLEASUREFARMCOMM'LRETAILSERVICEFOR HIRE

    GVW / GCW

    CLASS

    SIC

    FACTOR

    SEAT CP

    RADIUS

    FARTHEST TERMINAL

    COST NEW

    Drive to Work / School

    DRIVE

    NET VEH DR/CR:

    Coverage Details

    CHECK COVERAGES

    LIABNO-FAULTMED PAYUNINS MOTOR

    ADD'L COVERAGES

    TOWING & LABORSPEC C OF L

    DEDUCTIBLES

    COMP/OTC:

    COLL:

    ACV/ST AMT

    TOTAL PREM

    REMARKS (ACORD 101), Additional Remarks Schedule, may be attached if more space is required

    SIGNATURE

    AGENCY CUSTOMER ID:


    Applicable in AL, AR, DC, LA, MD, NM, RI and WV

    Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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. *Applies in MD Only.

    Applicable in CO

    It is unlawful to knowingly provide false, incomplete, or misleading facts or information 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Applicable in FL and OK

    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree).* *Applies in FL Only.

    Applicable in KS

    Any person who, knowingly and with intent to defraud, presents, causes to be presented 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 statement 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 conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

    Applicable in KY, NY, OH and PA

    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 to exceed five thousand dollars and the stated value of the claim for each such violation). *Applies in NY Only.

    Applicable in ME, TN, VA and WA

    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 and denial of insurance benefits. *Applies in ME Only.

    Applicable in NJ

    Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

    Applicable in OR

    Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

    Applicable in PR

    Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

    Certification

    The undersigned is an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application. He/she represents that the answers are true, correct, and complete to the best of his/her knowledge.

    PRODUCER'S SIGNATURE

    PRODUCER’S NAME
    (Please Print)

    STATE PRODUCER LICENSE NO
    (Required in Florida)

    APPLICANT'S SIGNATURE

    DATE

    NATIONAL PRODUCER NUMBER