SUTTER INSURANCE COMPANY 1301 Redwood Way, Suite 200, Petaluma, CA 94954-1136 COMMERCIAL AUTO PHYSICAL DAMAGE APPLICATION CA GENERAL INFORMATION 1. Name of Business: Individual Partnership Corporation 2. DBA : 3. Name of Person Signing Application: Title: 4. Mailing address: Street Address City State Zip 5. Applicant's business: 6. Years in Business: 7. Principal Garaging Address: Street Address City State Zip 8. Phone Number: ( ) 9. Date coverage desired: 10. Contact Name for Inspection: 11. Contact Phone Number: OPERATIONS What is applicant s DOT#? Name of Current Liability Carrier: What is applicant s maximum radius of operation? List all commodities carried: Policy Number: EXPLAIN ALL YES RESPONSES YES* NO EXPLAIN ALL NO RESPONSES YES NO* 1. With the exception of any encumbrances, are any vehicles not solely owned by and registered to the applicant? 2. Has insurance been cancelled or refused by any company in last three (3) years? 8. Does applicant understand that coverage being applied for will exclude vehicles rented or leased to others without drivers? 9. Do you order MVRs for all drivers prior to hire? 3. Has applicant ever been in an assigned risk plan? 10. Do you order MVR s for all drivers at least once yearly after employment? 4. Are PUC filings required? If Yes; Filing #: 11. Are drivers subject to pre-hire drug screening? 5. Are DMV filings required? If Yes; Filing #: 6. Are any vehicles customized, altered or have special equipment? 7. Are any vehicles listed on this application used by family members not listed as drivers on the application? * EXPLANATIONS: HISTORY PRIOR CARRIER AND LOSS HISTORY FOR THE PAST THREE YEARS From To Physical Damage Carrier Name Losses Policy No. Mo Yr Mo Yr (List Liability Carrier if no prior physical damage coverage) Number Amount $ $ $ $ Unit # Model Year Trade Name Body Type Subclass Code GVWR Identification # (VIN#, Serial #) Radius Coverage Limit Requested Owned or Leased 1 N/A 2 N/A 3 N/A VEHICLES 4 N/A 5 N/A 6 N/A 7 N/A 8 N/A 9 N/A 10 N/A Deductible Requested: $1,000 $2,500 $500 ($500 NOT AVAILABLE for Heavy or Extra Heavy Trucks/Tractors or Semi-Trailers?) SI 3054 (6-15) SUTTER INSURANCE COMPANY Page 1 of 3
# DRIVER'S FULL NAME Date of Birth Driver's License Info State License # No. Yrs. Commercial Driving No. Yrs. Employed By Applicant No. of Accidents Last 3 Yrs. No. of Minor Convictions Last 3 Yrs. No. of Major Convictions Last 3 Yrs. 1 2 3 4 5 DRIVER INFORMATION 6 7 8 9 10 6 7 8 9 10 ADDITIONAL INFORMATION 1. Does applicant employ drivers under age 25? YES NO If YES, are all such drivers listed on this application? YES NO 2. Does applicant understand that coverage being applied for will exclude coverage on vehicles being operated by drivers under age 25 that are not listed as drivers above or added to the policy by subsequent endorsement? YES NO 3. Does applicant understand that they will be required to report all new drivers to the company before they are allowed to operate any vehicles? YES NO The automobiles described above under Item Numbers corresponding to those indicated below are mortgaged as follows and loss, if any, under Comprehensive, Collision, Fire, Lightning or Transportation, Theft, or Combined Additional shall be payable to the named Insured and mortgagee named below, as their interest may appear. Auto # Name of Loss Payee Address of Loss Payee LEINHOLDERS REMARKS: SI 3054 (6-15) SUTTER INSURANCE COMPANY Page 2 of 3
NOTICE TO APPLICANT BY MY SIGNATURE I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE WITH THE FOLLOWING: 1. No insurance shall be effective until the Sutter Insurance Company (the Company), receives and approves this application, and advises the Applicant or its authorized Broker that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Broker named below is acting as the Applicant's Broker and not on behalf of the Company. The Applicant's Broker has no authority to bind coverage, may not accept any funds for the Company, and may not modify or interpret the terms of the policy; and 2. This is my full authorization to release a claim loss history on the policies listed in this application to the Company (Fax # 707-793-0909). This authorization does not authorize release of any specific records or documents in claim files. This authorization expires upon the expiration of any coverage extended as a result of this application; and 3. The Applicant agrees that any inspection of equipment, premises, operations, or inspection of any other matter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect; and 4. The Applicant understands that an inquiry may be made into the character, finances, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation; and 5. The Applicant represents that she/he has completed all relevant sections of this Application with the guidance of the Applicant s broker, prior to execution. The applicant further represents that the Applicant s Broker has reviewed and explained the coverage so that the Applicant understands all Coverages, Limitations and Exclusions contained in the insurance being requested; and 6. The Insurance applied for will EXCLUDE 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 7. A deductible equal to two times the deductible indicated on the policy declarations will apply to any claim involving a vehicle operator whose name you failed to report to us, or our authorized representative, prior to the loss or damage to the vehicle. This deductible is a separate aggregate deductible and applies in addition to any other deductible; and 8. This policy has a significant restriction for Towing and Storage expenses. We will 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; and 9. Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law; and 10. That the foregoing statements and answers are true and correct. I completed this application with the guidance of my broker as defined in Section 1623 of the California Insurance Code, who is indicated within this application and the facts stated herein are true and request the company to issue the Insurance policy and any renewals there from in reliance hereon. The Applicant agrees that if its statements and answers are materially false, the Company may rescind any policy or subsequent renewal it may issue. 11. I hereby apply for a policy of Insurance set forth above on the basis of statements contained herein, and that my Broker has reviewed and explained so that I understand all Coverages, Limitations and Exclusions contained in the Insurance being applied. Signature of Applicant: Date: NOTICE TO BROKER By my signature, I hereby declare that all Coverages, Limitations, and Exclusions contained in the Insurance being applied for have been reviewed with and explained to the applicant. Name of Applicant s Broker: License #: Street Address: City: State: Zip Code: Signature of Applicant s Broker: Date: SI 3054 (6-15) SUTTER INSURANCE COMPANY Page 3 of 3
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY LIMITATION OF USE ENDORSEMENT (LIMITING COVERAGE TO 48 STATES) ENDORSEMENT FOR USE WITH COMMERCIAL AUTO COVERAGE FORMS In consideration of the premium at which this policy is written, it is hereby understood and agreed that coverage shall be in effect under this policy only while a covered auto listed in the policy declarations or added by endorsement indicating a radius of or some representation thereof, is operated within the legal boundaries of the 48 contiguous States of the United States. Furthermore, NO COVERAGE is provided when a covered auto listed in the policy declarations or added by endorsement is operated for any reason outside of the legal boundaries of the 48 contiguous States of the United States or the countries of Canada and Mexico. COVERAGE WA MT ND ME OR ID WY SD MN WI MI NY VT NH MA RI CA NV UT CO NE KS IA MO IL OH IN KY WV PA VA CT NJ DE MD AZ NM OK AR TN NC SC TX LA MS AL GA FL SCHEDULE Covered Auto No. Year Make Model Radius Vehicle Identification Number (VIN) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. All other terms, conditions, and agreements of the policy shall remain unchanged. This endorsement forms a part of Policy No. issued to: by the SUTTER INSURANCE COMPANY and is effective at 12:01 A.M. on EFFECTIVE DATE at the principle garaging location indicated in the policy declarations 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) SI 3601 (2-15) SUTTER INSURANCE COMPANY Page 1 of 1
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. 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 (4-15) SUTTER INSURANCE COMPANY Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. The following is added to Exclusions: TERRORISM EXCLUSION This insurance does not apply to any and all coverage, including but not limited to, coverage for loss, damage, liability, cost or expense whether arising by contract or otherwise, that, in any way, form, or manner, directly or indirectly arises out of, is in connection with, or is related to, an act of Terrorism. As used in this endorsement, "Act of Terrorism" means an activity that: Involves a violent act or an act dangerous to human life, tangible or intangible property or infrastructure, causing damage to property or injury to persons within the United States, its territories and possessions, or a threat thereof; and appears to be intended to intimidate or coerce a civilian population, or disrupt any segment of the American economy, or influence the policy of a government by intimidation or coercion, or affect the conduct of a government by mass destruction, assassination, kidnapping or hostage taking. This endorsement excludes coverage for Certified Acts of Terrorism that is certified by the Secretary of State and the Attorney General of the United States, to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act of 2002, or an Act of Terrorism as defined above. This exclusion does not eliminate or exclude any coverage provided by this policy for the perils of vandalism and malicious mischief. An act of terrorism as defined in this endorsement is an act separate and distinct from an act of war. 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) SI 3375 (2-15) SUTTER INSURANCE COMPANY Page 1 of 1
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
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CHANGES This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE PHYSICAL DAMAGE COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The term "spouse" is replaced by the following: Spouse or registered domestic partner under California law. B. PREMIUMS The following paragraphs are added to Premiums under the policy CONDITIONS The first Named Insured shown in the Declarations: a) Is responsible for the payment of all premiums; and b) Will be the payee for any return premiums we pay. In the event of a total Loss or a constructive total loss to Covered Property by a Covered Cause of Loss, the entire policy premium will be fully earned and no return premium will be due. C. DEFINITIONS is amended and the following added: Constructive total Loss means the Covered Property damaged by a Covered Cause of Loss is treated as a total Loss because the cost of repairing the damaged Covered Property exceeds the actual cash value of the Covered Property at the time of Loss. SI 3603 (6-15) SUTTER INSURANCE COMPANY Page 1 of 1