Insurance Truck Policy

INSURANCE TRUCK POLICY

Policy Declarations

Policy Number:    Producer/Agent:

Effective Date:    Expiration Date:

Insured Information

Contact Phone:    Email:

Date of Birth:    Federal Tax ID / SSN:

Vehicle Schedule

Vehicle 1 - VIN:

Make/Model:    Year:    Gross Vehicle Weight Rating (GVWR):

Vehicle 2 - VIN:

Make/Model:    Year:    GVWR:

Coverages & Limits

Primary Liability Coverage:

Commercial Auto Liability - Bodily Injury & Property Damage   Limit: $

Cargo Liability   Limit: $    Deductible: $

Comprehensive and Collision (Physical Damage)   Per Vehicle Limit: $    Deductible: $

Uninsured/Underinsured Motorist   Limit: $

Premium & Payment

Payment Plan:    Payment Due Date:

Exclusions and Limitations

The coverage provided by this policy does not apply to loss or liability arising from the following unless otherwise endorsed: intentional acts, operating while intoxicated, use of vehicles in illegal transport of goods, noncompliant trailer connections, contractual liability accepted by insured beyond that specifically insured herein, punitive or exemplary damages where uninsurable by law, and any use of vehicles in racing or competitions. Additional exclusions may apply as set forth in the policy terms and conditions.

Claims and Notice

Insured must give prompt written notice to the company of any occurrence likely to give rise to a claim. Insured must cooperate with the company in the investigation and defense of claims, submit to examination under oath if requested, and provide copies of all relevant documents. Failure to timely report a loss may prejudice coverage under this policy.

Conditions — Insuring Agreement

In consideration of the payment of premium and subject to all terms, limitations, exclusions and conditions contained in this policy, the insurer agrees to provide the insurance described in the Declarations and Coverage sections for covered losses which occur during the policy period and arise out of the operation, maintenance or use of scheduled vehicles.

Endorsements / Special Provisions

Beneficiary Designation

Beneficiary Name:

Relationship to Insured:    Percentage of Payout:

Declarations and Certification

By signing below, the Applicant/Insured certifies that the information provided herein is true and complete to the best of the Applicant's knowledge. The Applicant acknowledges that material misrepresentation or omission of information relevant to underwriting or claims may result in denial of coverage, rescission of the policy, or adjustment of premiums. Applicant further agrees to comply with all policy provisions, cooperate with the insurer in the handling of claims, and notify the insurer promptly of any change in operations, vehicle schedule or exposures material to risk.

Acknowledgment of Receipt

The Applicant acknowledges receipt of the policy declarations and understands that coverage is subject to all terms, conditions, endorsements and exclusions contained in the policy documents. The Applicant authorizes the insurer to obtain records and information necessary for underwriting and claims handling to the extent permitted by law.

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