Insurance Truck Application

INSURANCE TRUCK APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership

Vehicle / Truck Details (Unit 1)

VIN:    Year:

License Plate #:    State:    GVWR (lbs):

Owned Leased Financed

Operation & Use

Radius of operation (miles):    Interstate Operations:

General freight Refrigerated Hazardous materials Household goods Passenger transport Other

Requested Policy & Coverage

Auto Liability Physical Damage (Comprehensive & Collision) Cargo Uninsured/Underinsured Motorist Bobtail

Requested Policy Period From:    To:

Safety, Maintenance & Driver Controls

ABS Air brakes GPS tracking Fire extinguisher Speed limiter

Drivers subject to pre-employment drug testing and background screening:    Applicant authorizes insurer to obtain motor vehicle records and loss history:

Prior Insurance & Loss History

Prior Policy Number:    Policy Period: From To

Any losses or claims in past 5 years:

Documentation Checklist

Attachments provided (check all that apply):

Vehicle registration Title / lease agreement Copies of driver licenses Prior policy declarations Loss runs Vehicle photos

Exclusions & Limitations

The insurance to be issued is subject to standard policy terms, conditions and exclusions. Notwithstanding any coverage requested, coverage will not apply to liability, loss or damage resulting from:

• Intentional acts or willful misconduct of the insured or operator.
• Wear and tear, gradual deterioration, mechanical or electrical breakdown unless specifically endorsed.
• Losses arising while the vehicle is used in the commission of a crime or while not listed and approved under the policy.
• Pollution and contamination except where specifically provided by endorsement.
• Nuclear hazard, war (declared or undeclared), insurrection, or government seizure.

Beneficiary / Loss Payee Designation

Primary Loss Payee Name:

Declarations, Certification & Authorization

I declare that I am authorized to make this application on behalf of the named insured and that the statements and answers set forth in this application are true and complete to the best of my knowledge. I understand that the insurer relies upon the representations made in this application in determining eligibility and premium. Any material misrepresentation, omission or concealment of fact may result in denial of coverage or rescission of the policy.

I authorize the insurer or its authorized representative to obtain loss history, motor vehicle records, underwriting and claim-related information and to disclose relevant policy, claim and investigative information to reinsurers, regulatory authorities, or other insurers as necessary for underwriting and claims handling. I agree that this application becomes part of any policy issued and that coverage, if bound, will be subject to the terms, limitations and exclusions contained in the policy.

I further certify that no other insurance has been effected covering the interests described herein except as listed on this application. I acknowledge that coverage is not effective until accepted and confirmed in writing by the insurer or its authorized agent.

Additional Information

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