Bind Instructions & EFT Authorization Form - Sutter Business Auto

Transcription

1 P.O. BOX 87023, YORBA LINDA, CA PHONE: Bind Instructions & EFT Authorization Form - Sutter Business Auto 1. Obtain signatures on application, UM waiver, and Terrorism disclosure. 2. The following items must be received within 5 days from effective date bound. Signed Application, UM waiver, Terrorism Declination Form and Supplement (if enclosed) MVR s for all drivers (dated within the past 30 days) Copy of attached Sutter Quote Current copy of registration showing the applicants name as registered owner Confirm Authorized EFT Amount indicated below* or Fax this form with above items to RMIS: commercial@rmismga.com Fax: *If the above information is not received within 5 days from date bound, coverage will be considered void. If received late a new effective date may be used. The checked billing option below was requested with your request prior to binding. The required deposit has been prefilled on the Authorized EFT Amount below. (Enclosed copy of quote provides payment details per billing option chosen). Agency Bill 25% gross deposit + $50 Policy Fee * If PAYING FULL AMOUNT, please request this option separately in writing as the required EFT amount below indicates deposit only Direct Bill 1/12 annual premium deposit + $50 Policy Fee Monthly Payment - 1/12 of annual premium + billing fee billed to insured directly Authorized EFT Amount: $ (Amount shown is the required down payment per the billing option selected above.) Producer Code: Producer Name: Tel#: Applicant s Name: Date: *If you are not an Authorized EFT Producer you will have to mail a check to RMIS for the down payment. Please provide copy of check being mailed with items needed to bind listed above. If you are not an Authorized EFT Producer, please complete the EFT information below. ***** Section below applies to Producers NOT already set up for EFT ***** Authorization for Electronic Funds Transfers I,, give Robert Moreno Insurance Services the authorization to withdraw the appropriate RMIS money that has been deposited into the brokerage s trust account. I further authorize the financial institution named below to accept such automatic deposits to or withdrawals from my account by Robert Moreno Insurance Services and to automatically credit or debit, as the case may be, such amounts. Banking Institution Name: Routing Number Account Number I understand that I may cancel this authorization at any time. To cancel, I must give written notice to RMIS. My cancellation will become effective when RMIS receives my written request to cancel and has a reasonable period of time upon which to process. I further understand that all automatic deposits to or withdrawals from my account under this authorization will be subject to all rules, regulations, agreements and disclosure statements of the company and the institution governing accounts and pre-authorized transfers to and from this account. Brokerage Name Producer Code(s) Signature X Date / /

2 APPLICATION FOR BUSINESS AUTO POLICY UNDERWRITTEN BY SUTTER Insurance Company SUBMIT TO: Commercial Auto Department Robert Moreno Insurance Services P.O. Box Yorba Linda, CA Tel Fax GENERAL INFORMATION 1. Name of applicant Individual Partnership Corporation 2. Mailing address Street Address City County State Zip 3. Applicant's business Years in business 4. Principal garaging location Phone Number ( ) 5. Proposed effective date Proposed expiration date 6. What is Applicants maximum radius of operation? 7. Is employer's Non-Ownership and Hired Car Coverage being applied for? Yes No If yes, what is number of employees using autos in insured's business? What is the annual cost of hired cars? $ 8. Does the applicant have existing or require any new filings or certificates with the DMV or DOT? Yes No If yes, describe 9. Is the applicant the registered owner of the vehicle(s) to be insured? Yes No If no, explain 10. Liability Limits Requested: 15,000/30,000/10,000 50,000/100,000/50, ,000/500,000/100, ,000 CSL 500,000 CSL 1,000,000 CSL Other (Specify): 11. Other Limits Requested: 1,000 Med Pay PRIOR CARRIER AND LOSS HISTORY FOR THE PAST THREE YEARS From To Liability Losses Physical Damage Losses Company Name Policy No. Mo Yr Mo Yr Number Amount Number Amount Has insurance been cancelled or refused by any company in last 3 years? Yes No Explain # DRIVER'S FULL NAME Date of Birth DRIVER INFORMATION Driver's License Info. State License No. No. Yrs. Comm'l Driving Does applicant employ drivers under age 25? Yes No 2. Number of drivers employed for under 1 year? 3. Are driving records checked and ordered on new drivers at or prior to employment? Yes No DESCRIPTION OF VEHICLES # YEAR MAKE / MODEL BODY TYPE V.I.N. MFG s RATED GROSS VEHICLE WEIGHT Loss Payees or Additional Interests: No. Yrs. Empl. By Applicant No. of Accidents Last 3 Yrs. CURRENT VALUE No. of Minor Violations Last 3 Yrs. Deductible Spec Peril / Collision No. of Major Violations Last 3 Yrs. USE (Comm l, Retail, Service) Loss Payees or Additional Interests: SI3202 (9-.09) SUTTER INSURANCE COMPANY Page 1 of 2

3 CALIFORNIA UNINSURED / UNDERINSURED MOTORISTS INSURANCE REQUIREMENT SELECTION / REJECTION The California Insurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance or use of a motor vehicle. Uninsured motorists coverage insures the insured, his heirs, or legal representatives for all sums within the limits established by law, which such person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to him from the owner or operator of an uninsured motor vehicle not owned or operated by the insured. If the Sutter Insurance Company issues coverage to the applicant In accordance with the California Insurance Code (Section (a)), the insured: INDICATE COVERAGE DESIRED BY AN X agrees that the Uninsured Motorist Coverage afforded in the policy is hereby rejected in its entirety. agrees that the Uninsured Motorist Coverage is to be provided at the financial responsibility limits of $15,000 each person and $30,000 each accident. agrees that the Uninsured Motorist Coverage is to be provided at the higher limits of $30,000 each person and $60,000 each accident. Any selection / rejection of coverage indicated on this form will be carried forward on all renewals issued by the company unless the insured advises us in writing. In the event the policy names more than one individual in the declarations, each of you must sign. By my signature I acknowledge that I have made the selection indicated above and that I understand that THERE IS A PREMIUM CHARGE FOR THIS COVERAGE and I agree to pay same if coverage is selected: Signature of Applicant: Date: NOTICE TO APPLICANT Thank you for considering Sutter Insurance Company as your insurance carrier. As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. By my signature I acknowledge that I understand and agree with the following: 1. that with the guidance of my broker as defined in Section 1623 of the California Insurance Code, who is indicated within this application and do hereby apply for a policy of Insurance set forth above on the basis of statements contained herein; and 2. that the facts stated herein to be true and request the company to issue the Insurance policy and any renewals there from in reliance hereon; and 3. that the Insurance applied for will EXCLUDE coverage on any covered auto while it is in the custody of or operated by drivers LESS THAN 25 years of age, unless such person is named as a driver in this application or is added by endorsement to the policy; and 4. that the Insurance applied for will EXCLUDE coverage on any covered auto that is rented or leased to others without drivers; and 5. that no Insurance is bound hereunder and that no Insurance shall be effective until the company, or its authorized representative approves this application; and 6. that the Insurance being applied for does not provide coverage for Bodily Injury, Property Damage or Physical Damage arising out of the maintenance, use or operation of any covered auto during the policy period: a. which is being operated frequently or regularly beyond the radius of operation show in the policy declarations; or b. with a manufacturers rated gross vehicle weight greater than that recorded in the policy declarations. This may be different from a CVRA rating with the Department of Motor Vehicles; or c. with a manufacturer s rated gross vehicle weight over 20,000 pounds. This may be different from a CVRA rating with the Department of Motor Vehicles; or d. when combined with another auto (motor vehicle and trailer), and the combined manufacturers rated gross vehicle weight is greater than that recorded in the policy declarations. 7. that depending on the vehicle size and use, the California Department of Motor Vehicles requires that certain commercial autos carry limits of liability up to $750,000. The applicant hereby acknowledges that they are aware of such requirements and represents that the limits being applied for on this application are in compliance with Department of Motor Vehicles Regulations; and 8. That this program may be available with a monthly payment option, and that there will be a BILLING FEE each billing cycle that the annual premium balance is not paid in full as follows: WRITTEN ANNUAL PREMIUM MONTHLY BILLING FEE $0 - $5,000 $15 $5,001 - $10,000 $25 $10,001 - $20,000 $50 $20,001 AND ABOVE $100 Signature of Applicant: Date: NOTICE TO BROKERS By my signature I hereby declare that I am a broker as defined by Section 1623 of the California Insurance Code and that I have reviewed with, and explained to the applicant all coverage s, limitations and exclusions contained in the insurance being applied for. Name of Producing Broker: CDI License #: Address: City: Signature of Broker: Date: SI3202 (9-.09) SUTTER INSURANCE COMPANY Page 2 of 2

4 SUTTER Insurance Company CALIFORNIA UNINSURED (INCLUDING UNDERINSURED) MOTORIST INSURANCE REQUIRMENT SELECTION / REJECTION FORM POLICY NUMBER NAMED INSURED The California Insurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance or use of a motor vehicle Uninsured motorists coverage insures the insured, his heirs, or legal representatives for all sums within the limits established by law, which such person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to him from the owner or operator of an uninsured motor vehicle not owned or operated by the insured. In accordance with the California Insurance Code (Section (a)), the insured (and each of them): INDICATE BY AN X agrees that the Uninsured Motorist Coverage afforded in the policy is hereby rejected in its entirety. agrees that the Uninsured Motorist Coverage is to be provided at the financial responsibility limits of $15,000 each person and $30,000 each accident. agrees that the Uninsured Motorist Coverage is to be provided at the higher limits of $30,000 each person and $60,000 each accident. Any selection / rejection of coverage indicated on this form will be carried forward on all renewals issued by the company unless the insured advises us in writing. In the event the policy names more than one individual in the declarations, each of you must sign. You understand that THERE IS A PREMIUM CHARGE FOR THIS COVERAGE and you agree to pay same if coverage is selected. Signature of Insured Date Signature of Insured Date SI 3215

5 SUTTER Insurance Company POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Under the Terrorism Risk Insurance Act of 2002, effective November 26, 2002 (the Act ), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The term certified act of terrorism means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion; and that causes losses of at least $5,000,000. You should know that coverage for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States pays 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium for this coverage is shown below and does not include any charges for the portion of loss covered by the federal government under the Act. IN ACCORDANCE WITH THE ACT, YOU MUST CHOOSE TO ACCEPT OR REJECT COVERAGE FOR CERTIFIED ACTS OF TERRORISM. SELECTION OR REJECTION OF CERTIFIED TERRORISM INSURANCE COVERAGE XXX I hereby elect to purchase certified terrorism coverage for a prospective premium of $ 30. I hereby reject the purchase of certified terrorism coverage. Policyholder/Applicant s Signature Print Name Policy Number, if available Date SI3420 (9-07) SUTTER INSURANCE COMPANY Page 1 of 1

6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL TOWING COVERAGE LIMITATION ENDORSEMENT FOR USE WITH COMMERCIAL AUTO PHYSICAL DAMAGE PART This endorsement modifies insurance provided under the following: SECTION il LIMIT OF LIABILITY The following is added: d. We will also pay up to $5000 for the combined towing, storage and labor costs resulting from the ownership, maintenance or use of a covered automobile that is involved in a covered loss to which this insurance applies. For towing, we will only pay for towing by a qualified towing service for the cost to the nearest repair facility capable of making the necessary repairs, unless we agree with you in advance to tow to another repair facility. Additionally, we will only pay for labor performed at the place of disablement and for storage required to complete the necessary repairs. The most we will pay for loss to any one covered automobile, including Commercial Towing Expenses, is the applicable limit defined in a. through c. Charges associated with the recovery, storage, salvage or removal of cargo are not covered hereunder. All other terms, conditions, and agreements of the policy shall remain unchanged. By signing below I am verifying that I have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that I have requested and received and is properly limited as indicated. X Applicant s Signature (Required) Date (Required) SI3566 (5-13) SUTTER INSURANCE COMPANY Page 1 of 1

7 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PHYSICAL DAMAGE AGGREGATE SUB-LIMIT ENDORSEMENT FOR USE WITH COMMERCIAL AUTO PHYSICAL DAMAGE PART This endorsement modifies insurance provided under the following: SECTION Il LIMIT OF LIABILITY The following is added: e. The total limit of liability for loss to more than one covered automobile resulting from any one event shall be $200,000, unless a premium for a higher limit is indicated on the policy declarations or added by endorsement SECTION IV DEFINITIONS The following definition is added: event includes continuous or repeated exposure to a collision or covered peril (unless specifically excluded) resulting in property damage. All other terms, conditions, and agreements of the policy shall remain unchanged. By signing below I am verifying that I have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that I have requested and received and is properly limited as indicated. X Applicant s Signature (Required) Date (Required) SI3594 (11-14) SUTTER INSURANCE COMPANY Page 1 of 1