COMMERCIAL AUTO FACT FINDER

Transcription

1 COMMERCIAL AUTO FACT FINDER CUSTOMER INFORMATION EFFECTIVE DATE: EXPIRATION DATE: INSURED NAME (as it should appear on the ID cards) INDIVIDUAL (Last Name, First Name): OR BUSINESS NAME: MAILING ADDRESS: COUNTY: STATE: ZIP CODE: BILLING ADDRESS (If different from mailing address): PHONE #: BUSINESS PHONE #: SOCIAL SECURITY/EIN#: DOB: TYPE OF BUSINESS: OWNERSHIP (ONE ENTITY PER POLICY): Place an X next to the entity for this client. Individual Corporation Partnership Joint Venture Limited Liability Corp Limited Liability Partnership Trust Estate EXISTING ACCOUNT: YES NO CLIENT ACCOUNT #: ACCOUNT CREDIT: YES NO YEARS IN BUSINESS: CURRENT INSURANCE CARRIER: POLICY # CURRENT CARRIER: CURRENT POLICY TERM: UMBRELLA POLICY with our company? YES NO Select type: Commercial Farm Personal If the client is also applying for a Personal, Farm or Commercial Umbrella with the Company, or already has such a policy with this company, the Business Auto policy must be issued with the Umbrella minimum underlying limits for Bodily Injury and Property Damage. Review the requirements for your state. Please note that Hired/Non-Owned Auto coverage is required for Commercial Umbrellas. X-3826 Ed.02/16/07 1

2 VEHICLE/CLASS INFORMATION INFORMATION REQUIRED FOR EACH INSURED VEHICLE Vehicle: 1 Note: Private Passenger Vehicles can only be insured on a Commercial Auto policy if owned and registered by a Corporation. VEHICLE TYPE: 1. Commercial Truck/Trailer 2. Private Passenger 3. Farm Equipment 4. Land Motor Vehicle Other Than Farm Equipment VIN: YEAR: MAKE: MODEL: BODY/STYLE: GROSS VEHICLE WEIGHT: RADIUS OF OPERATION: BUSINESS USE: 1. Service 2. Retail 3. Commercial Classification Service Use Definition For those vehicles used for transporting the insured's personnel, tools, equipment and supplies to or from a job location. Vehicles are principally parked at the job location the majority of the working day or used to transport supervisory personnel between job sites. Retail Use Commercial Use For those vehicles used to pick up or deliver property to individual homes. For those vehicles used for transporting property in a manner other than described as either retail or service. INDUSTRY CLASS: 1. Truckers 2. Food Delivery 3. Farmer 4. Dump and Transit Mix Trucks and Trailers 5. Contractor 6. Not Otherwise Classified TYPE OF GOODS HAULED: CAPABLE OF DUMPING LOAD: YES NO ORIGINAL COST NEW: $ SEASONAL AGRICULTURAL PRODUCE TRAILER: YES NO NUMBER OF MONTHS IN USE: SEASONAL FARM USE CREDIT: YES NO SFP 10 POLICY NUMBER: Note: A SFP 10 policy (excluding Country Estate) must be in force to qualify for Seasonal Farm Use Credit. Please review the eligibility guidelines in your state. ANTI THEFT DEVICE: (KENTUCKY, LOUISIANNA, MINNESOTA ONLY) YES NO RESTRAINT (PRIVATE PASSENGER NEVADA ONLY): YES NO X-3826 Ed.02/16/07 2

3 Vehicle: 2 VEHICLE TYPE: 1. Commercial Truck/Trailer 2. Private Passenger 3. Farm Equipment 4. Land Motor Vehicle Other Than Farm Equipment VIN: YEAR: MAKE: MODEL: BODY/STYLE: GROSS VEHICLE WEIGHT: RADIUS OF OPERATION: BUSINESS USE: 1. Service 2. Retail 3. Commercial INDUSTRY CLASS: 1. Truckers 2. Food Delivery 3. Farmer 4. Dump and Transit Mix Trucks and Trailers 5. Contractor 6. Not Otherwise Classified TYPE OF GOODS HAULED: CAPABLE OF DUMPING LOAD: YES NO ORIGINAL COST NEW: $ SEASONAL AGRICULTURAL PRODUCE TRAILER: YES NO NUMBER OF MONTHS IN USE: SEASONAL FARM USE CREDIT: YES NO SFP 10 POLICY NUMBER: ANTI THEFT DEVICE: (KENTUCKY, LOUISIANNA, MINNESOTA ONLY) YES NO RESTRAINT (PRIVATE PASSENGER NEVADA ONLY): YES NO Vehicle: 3 VEHICLE TYPE: 1. Commercial Truck/Trailer 2. Private Passenger 3. Farm Equipment 4. Land Motor Vehicle Other Than Farm Equipment VIN: YEAR: MAKE: MODEL: BODY/STYLE: GROSS VEHICLE WEIGHT: RADIUS OF OPERATION: BUSINESS USE: 1. Service 2. Retail 3. Commercial INDUSTRY CLASS: 1. Truckers 2. Food Delivery 3. Farmer 4. Dump and Transit Mix Trucks and Trailers 5. Contractor 6. Not Otherwise Classified TYPE OF GOODS HAULED: CAPABLE OF DUMPING LOAD: YES NO ORIGINAL COST NEW: $ SEASONAL AGRICULTURAL PRODUCE TRAILER: YES NO NUMBER OF MONTHS IN USE: SEASONAL FARM USE CREDIT: YES NO SFP 10 POLICY NUMBER: ANTI THEFT DEVICE: (KENTUCKY, LOUISIANNA, MINNESOTA ONLY) YES NO RESTRAINT (PRIVATE PASSENGER NEVADA ONLY): YES NO X-3826 Ed.02/16/07 3

4 Vehicle: 4 VEHICLE TYPE: 1. Commercial Truck/Trailer 2. Private Passenger 3. Farm Equipment 4. Land Motor Vehicle Other Than Farm Equipment VIN: YEAR: MAKE: MODEL: BODY/STYLE: GROSS VEHICLE WEIGHT: RADIUS OF OPERATION: BUSINESS USE: 1. Service 2. Retail 3. Commercial INDUSTRY CLASS: 1. Truckers 2. Food Delivery 3. Farmer 4. Dump and Transit Mix Trucks and Trailers 5. Contractor 6. Not Otherwise Classified TYPE OF GOODS HAULED: CAPABLE OF DUMPING LOAD: YES NO ORIGINAL COST NEW: $ SEASONAL AGRICULTURAL PRODUCE TRAILER: YES NO NUMBER OF MONTHS IN USE: SEASONAL FARM USE CREDIT: YES NO SFP 10 POLICY NUMBER: ANTI THEFT DEVICE: (KENTUCKY, LOUISIANNA, MINNESOTA ONLY) YES NO RESTRAINT (PRIVATE PASSENGER NEVADA ONLY): YES NO OTHER VEHICLE TYPES These liability coverages are added to the isolutions application on the Vehicle/Class screen. Each coverage will be reflected on the application as an additional vehicle. NON-OWNERSHIP: Number of Employees (full and part-time): HIRED AUTO (LIABILITY ONLY): Annual Cost of Hire: (min $1000) When hiring an auto, is the insured required to carry the Primary Insurance? Yes No HIRED AUTO (PHYSICAL DAMAGE without Drivers): If coverage is needed, add Comprehensive and Physical Damage deductibles. PARTNERSHIP NON-OWNERSHIP: Number of Partners: DRIVE OTHER CAR: Name of Driver: Name of Driver: If there are more vehicles, please use a separate piece of paper and gather the same information. X-3826 Ed.02/16/07 4

5 DRIVER INFORMATION MVR IS REQUIRED FOR EACH DRIVER Driver: 1 Driver: 2 Driver: 3 Driver: 4 X-3826 Ed.02/16/07 5

6 Driver: 5 Driver: 6 Driver: 7 Driver: 8 If there are more Drivers, please use a separate piece of paper and gather the same information.. X-3826 Ed.02/16/07 6

7 FAMILY MEMBERS NOT LISTED AS DRIVERS INFORMATION REQUIRED FOR EACH FAMILY MEMBER Family Member: 1 MIDDLE: LAST: DOB: RELATIONSHIP TO INSURED: REASON WHY NOT LISTED AS DRIVER: Family Member: 2 MIDDLE: LAST: DOB: RELATIONSHIP TO INSURED: REASON WHY NOT LISTED AS DRIVER: Family Member: 3 MIDDLE: LAST: DOB: RELATIONSHIP TO INSURED: REASON WHY NOT LISTED AS DRIVER: ALTERNATE GARAGE INFORMATION VEHICLE NUMBER: MAKE: MODEL: EXPLANATION FOR ALTERNATE GARAGE: CITY: STATE: ZIP: RATING TERRITORY: LOSS EXPERIENCE Gather All Loss Information Regardless of Date, Type, or Amount (Use Separate sheet of Paper if Necessary) DATE OF LOSS LOSS AMOUNT EXPENSE AMOUNT TYPE OF LOSS A Full description of Each Loss is Required X-3826 Ed.02/16/07 7

8 VEHICLE/CLASS COVERAGE Availability of coverage is state specific. Review F.A.R.M for available coverage and limits in your state. Note: Each vehicle must carry the same Combined Single Limit (CSL). The limits for Uninsured and Underinsured must be uniform on all vehicles and cannot be greater than the CSL. Vehicle: 1 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: Vehicle: 2 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: Vehicle: 3 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: X-3826 Ed.02/16/07 8

9 Vehicle: 4 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: Vehicle: 5 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: Vehicle: 6 LIABILITY LIMIT (CSL): UNINSURED MOTORISTS: MEDICAL PAYMENTS: UNDERINSURED MOTORISTS: TOWING AND LABOR (Private Passenger Type Only): SOUND RECEIVING EQUIPMENT (Make, Model, Serial Number & Cost New Required): RENTAL REIMBURSEMENT: LOSS OF USE EXPENSES - RENTAL VEHICLES: FELLOW EMPLOYEE COVERAGE: X-3826 Ed.02/16/07 9

10 ADDITIONAL INTERESTS INFORMATION REQUIRED PER VEHICLE Interest: 1 LOAN NUMBER: LOAN EXPIRATION DATE: COPY OF DEC: Yes No INTEREST TYPE: DESCRIPTION OF INTEREST: LAST NAME: OR BUSINESS NAME: ADDRESS: Interest: 2 LOAN NUMBER: LOAN EXPIRATION DATE: COPY OF DEC: Yes No INTEREST TYPE: DESCRIPTION OF INTEREST: LAST NAME: OR BUSINESS NAME: ADDRESS: Interest: 3 LOAN NUMBER: LOAN EXPIRATION DATE: COPY OF DEC: Yes No INTEREST TYPE: DESCRIPTION OF INTEREST: LAST NAME: OR BUSINESS NAME: ADDRESS: Interest: 4 LOAN NUMBER: LOAN EXPIRATION DATE: COPY OF DEC: Yes No INTEREST TYPE: DESCRIPTION OF INTEREST: LAST NAME: OR BUSINESS NAME: ADDRESS: X-3826 Ed.02/16/07 10

11 GENERAL UNDERWRITING INFORMATION Yes No 1. With the exception of liens or leases, are any vehicles not solely owned by or registered to the applicant? Yes No 2. Are any vehicles customized, altered or have special equipment? Yes No 3. Is there any existing damage to any vehicle (including damaged glass)? Yes No 4. Has any applicant had losses in the last 5 years that would be covered by this type of insurance? Yes No 5. Has any driver been in the assigned risk plan during the past 3 years? Yes No 6. Has any applicant been insured by this company on a policy issued under a different name? Yes No 7. Does the applicant have any other insurance with this company (list policy numbers)? Yes No 8. Do any of the employees use their automobiles in the business? Yes No 9. Has the license of any driver been suspended or revoked within the last 5 years? Yes No 10. Does any driver have a physical and/or mental impairment? Yes No 11. Has there been any financial responsibility filing (if yes, name of driver and date of filing)? Yes No 12. Has any applicant been convicted of any other type of crime? Yes No 13. Has any applicant been convicted of any degree of arson within 10 years of the application date? Yes No 14. Has any insured filed for bankruptcy within the last 5 years? X-3826 Ed.02/16/07 11

12 Yes No 15. Are ICC, PUC or other DOT filing required? Yes No 16. Has any vehicle NOT been inspected by agent? _ Yes No 17. Does the applicant haul goods for others for hire? Yes No 18. Are there any Bobtail operations? Yes No 19. Are there any other commercial vehicles owned by the applicant not insured on this policy? Yes No 20. Is there any seasonal use of rental vehicles? Yes No 21. Does the applicant obtain MVR s on new drivers and do periodic updates on existing drivers? Yes No 22. Is the primary address a PO Box? If yes, please enter physical location. Yes No 23. Do any of the following hand rated items apply? a. Hired Auto with Physical Damage (with drivers) b. Pollution Liability c. Buses d. Van Pools e. Zone Rate Vehicles f. Driver Exclusion g. Trucks of Limited Plate Registration with PIP Options 10, 11 or (NJ Only) AGENT CHECKLIST Submission Requirements for all applications: MVRS FOR ALL DRIVERS. COPY OF THE PRIOR / CURRENT DECLARATIONS PAGE. CURRENT LOSS RUNS (5 YEARS). COVERAGE SELECTION FORMS, IF APPLICABLE IN YOUR STATE. SEASONAL FARM USE SUPPLEMENTAL UNDERWRITING QUESTIONNAIRE, FORM ANX 3149, IF APPLICABLE. X-3826 Ed.02/16/07 12