SUTTER INSURANCE COMPANY 1301 Redwood Way, Suite 200, Petaluma, CA COMMERCIAL VEHICLE APPLICATION CA

Transcription

1 G L UTT UC CMPY 1301 edwood Way, uite 200, Petaluma, C CMMCL VHCL PPLCT C 1. ame of Business: ndividual Partnership Corporation 2. DB : 3. ame of Person Completing pplication: Title: 4. Mailing address: treet ddress City tate Zip 5. pplicant's business: 6. Years in Business: 7. Principal Garaging ddress: treet ddress City tate Zip 8. Phone umber: ( ) 9. Date coverage desired: 10. stimated financial worth: $ 11. Gross receipts/last year: $ 12. stimated next year: $ 13 Contact ame for nspection: Contact Phone umber: P T H T Y D V F M T 1. Does applicant rent or lease equipment to others without drivers?.. Yes o 2. What is applicants DT#? 3. What is the California DMV Filing #? 4. Does applicant operate under a Federal Filing (MC-90)?.. Yes o f Yes ; under whose filing (ttach a copy of the contract to this application if not under your own filing)? What is the MC#? 5. List furthest state vehicles are operated in? 6. re there any vehicles WD or PTD by the pplicant (including non-operational units) T listed on the application?.. Yes o f Yes, xplain why they are not listed: 7. List all cargo commodities carried: 8. Does applicant own cargo?... Yes o f o then who owns it? 9. Does applicant Hire quipment?... Yes o f Yes, what is estimated annual cost of hire? : $ s Hired uto coverage contractually required?... Yes o 10. Does applicant use sub-haulers?.... Yes o 11. Does applicant operate in the ports and/or require the applicable endorsements? Yes o 12. What is applicant s maximum radius of operation? P C D L HTY F TH PT TH Y From To Liability Losses Physical Damage Losses Company ame Policy o. Mo Yr Mo Yr umber mount umber mount Has insurance been cancelled or refused by any company in the last 3 years? Yes o xplain: # Driver s Full ame * List all accidents in which you were principally at fault Date of Birth Driver's License nfo tate License umber o. Yrs. Commercial Driving o. of ccidents * Last 36 Months o. of Minor Convictions Last 36 Months DDTL FMT 1. Does applicant employ drivers under age 25?.. Yes o 2. Do all drivers hold Class license?.... Yes o 3. umber of drivers employed for L TH 1 year: 4. re driving records checked and ordered on new drivers at or prior to employment?.... Yes o o. of Major Convictions Last 36 Months T5000 (6-13) UTT UC CMPY Page 1 of 2

2 Liability Limits equested: Liability (each accident): $ Uninsured Motorist Bodily njury (each accident): $ Medical Payments (each accident): $ Uninsured Motorist Property Damage (each accident): $ V H C L UT Y MDL TD M BDY TYP DTFCT # (V#, L #) GVW LBLTY DU WD LD TH 5 P H Y C L D M G F PHYCL DMG CVG QUTD, CMPLT PC BLW DTL F CH PCTV UT BV: UT DT PUCHD M Y CVG LMT (CV) TC T PPLCT DDUCTBL PHYCL DMG DU LHLD BY MY GTU CKWLDG THT UDTD D G WTH TH FLLWG: 1. This is my full authorization to release a claim loss history on the policies listed in this application to the utter nsurance Company Fax # This authorization does not authorize release of any specific records or documents in your claim files. This authorization expires upon the expiration of any coverage extended as a result of this application. This authorization is in compliance with the California nsurance Code; rticle 6.6 nsurance and Privacy Protection ct, ection and , and Title 10, California Code of egulations, ections through ; and 2. routine inquiry may be made by utter 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; and 3. Depending on the 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 the Department of Motor Vehicle egulations; and 4. completed this application with the guidance of my broker as defined in ection 1623 of the California nsurance Code, who is indicated within this application: and 5. hereby apply for a policy of nsurance set forth above on the basis of statements contained herein, and that my Broker has reviewed and explained so that understand all Coverages, Limitations and xclusions contained in the nsurance being applied for; and 6. The facts stated herein are true and request the company to issue the nsurance policy and any renewals there from in reliance hereon; and 7. The nsurance applied for will XCLUD coverage on any covered auto while it is in the custody of or operated by drivers under 25 years of age, unless such person is named as a driver in this application or is added by endorsement to the policy, and vehicles rented or leased to others without drivers; and 8. o insurance shall be effective until utter, or its authorized representative, receives and approves this application; and 9. This program may be available with a monthly payment option from UTT, and that if this option is elected there will be: a $20 BLLG F applied to each installment and supplemental bill as long as the annual premium balance is not paid in full, a $20 LT PYMT F applied to any payment not postmarked or received by the due date, a $25 TUD PYMT F if any payment is returned by your financial institution. ignature of pplicant: Date: TC T BK By my signature hereby declare that all Coverages, Limitations, and xclusions contained in the nsurance being applied for have been reviewed with and explained to the applicant. ame of pplicant s Broker: License #: treet ddress: City: tate: Zip Code: ignature of pplicant s Broker: T5000 (6-13) UTT UC CMPY Page 2 of 2 Date:

3 TH DMT CHG TH PLCY. PL D T CFULLY. LMTT F U DMT (LMTG CVG T PCFD DU D CLF) DMT F U WTH CMMCL UT CVG FM This endorsement modifies insurance provided under the following: CT ll LBLTY CVG B. XCLU The following is added when the declarations page indicates a premium for Liability Coverage: This insurance does not apply to Bodily njury or Property Damage arising out of the maintenance, use, or operation of any covered auto listed in the CHDUL below: a. which is being operated at any time beyond the radius of operations shown in tem 3 of the policy declarations; or b. which is being operated at any time beyond the legal boundaries of the state of California; or c. with a manufacturers rated gross vehicle weight greater than that recorded in the declarations or by subsequent endorsement; or d. when combined with another auto (motor truck and trailer), and the combined manufacturers rated gross vehicle weight is greater than that recorded in the declarations or by subsequent endorsement. CHDUL Covered uto o. Year Make Model adius Vehicle dentification umber (V) nformation required to complete this chedule, if not shown above, will be shown in the Declarations. ll other terms, conditions, and agreements of the policy shall remain unchanged. This endorsement forms a part of Policy o. issued to: by the UTT UC CMPY and is effective at 12:01.M. on FFCTV DT at the principle garaging location indicated in the policy declarations By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s ignature (equired) Date (equired) T 5003 (1-13) UTT UC CMPY Page 1 of 1

4 TH DMT CHG TH PLCY. PL D T CFULLY. LMTT F U DMT (LMTG CVG T CLF) DMT F U WTH CMMCL UT PHYCL DMG PT This endorsement modifies insurance provided under the following: CT l CVG GMT XCLU The following is added when the declarations page indicates a premium for Collision Coverage: This insurance does not apply to loss arising out of the maintenance, use, or operation of any covered auto listed in the CHDUL below: a. which is being operated at any time beyond the radius of operations shown in tem 3 of the policy declarations; b. which is being operated at any time beyond the legal boundaries of the state of California; or c. with a manufacturers rated gross vehicle weight greater than that recorded in the declarations or by subsequent endorsement; or d. when combined with another auto (motor truck and trailer), and the combined manufacturers rated gross vehicle weight is greater than that recorded in the declarations or by subsequent endorsement. CHDUL Covered uto o. Year Make Model adius Vehicle dentification umber (V) nformation required to complete this chedule, if not shown above, will be shown in the Declarations. ll other terms, conditions, and agreements of the policy shall remain unchanged. This endorsement forms a part of Policy o. issued to: by the UTT UC CMPY and is effective at 12:01.M. on FFCTV DT at the principle garaging location indicated in the policy declarations By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s ignature (equired) Date (equired) 024 (5-13) UTT UC CMPY Page 1 of 1

5 UTT nsurance Company CLF UUD (CLUDG UDUD) MTT UC QUMT LCT / JCT FM PLCY UMB M UD The California nsurance 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. n accordance with the California nsurance Code (ection (a)), the insured (and each of them): DCT BY 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 $ each person and $ each accident. agrees that the Uninsured Motorist Coverage is to be provided at the higher limits of $ combined single limit each accident. ny 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. n the event the policy names more than one individual in the declarations, each of you must sign. You understand that TH PMUM CHG F TH CVG and you agree to pay same if coverage is selected. ignature of nsured Date ignature of nsured Date T 5005 (7/02)

6 UTT nsurance Company PLCYHLD DCLU TC F TM UC CVG Under the Terrorism isk nsurance ct of 2002, effective ovember 26, 2002 (the ct ), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in ection 102(1) of the ct: The term certified act of terrorism means any act that is certified by the ecretary of the Treasury, in concurrence with the ecretary of tate, and the ttorney General of the United tates 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 tates, or outside the United tates in the case of an air carrier or vessel or the premises of a United tates 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 tates or to influence the policy or affect the conduct of the United tates 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 tates under a formula established by federal law. Under this formula, the United tates 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 ct. CCDC WTH TH CT, YU MUT CH T CCPT JCT CVG F CTFD CT F TM. LCT JCT F CTFD TM UC CVG X hereby elect to purchase certified terrorism coverage for a prospective premium of $ 30. hereby reject the purchase of certified terrorism coverage. Policyholder/pplicant s ignature Print ame Policy umber, if available Date 3420 (9-07) UTT UC CMPY Page 1 of 1

7 TH DMT CHG TH PLCY. PL D T CFULLY. CMMCL TWG CVG LMTT DMT F U WTH CMMCL UT PHYCL DMG PT This endorsement modifies insurance provided under the following: CT il LMT F LBLTY 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. dditionally, 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 xpenses, is the applicable limit defined in a. through c. Charges associated with the recovery, storage, salvage or removal of cargo are not covered hereunder. ll other terms, conditions, and agreements of the policy shall remain unchanged. By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s ignature (equired) Date (equired) 3566 (5-13) UTT UC CMPY Page 1 of 1