CALIFORNIA COMMERCIAL AUTO INSURANCE APPLICATION VICTORY AUTO Builders & Tradesmen s Ins. Services, Inc. License # 0D07 660 Sierra College Blvd., Rocklin, CA 95677 96-77-900 96-77-99 Fax APPLICANT INFORMATION BROKER INFORMATION Individual Partnership Corporation Joint Venture AGENCY NAME AND ADDRESS AGENCY CODE Subchapter S Corporation Not for Profit Organization Applicant Applicant s Telephone # TELEPHONE # Street address Contact Person Contact email: FAX # City State Zip Inspection Contact Telephone # Mailing Address (if different than location) POLICY INFORMATION SUBMISSION NUMBER: POLICY EFFECTIVE DATE: Time: :0 a.m. POLICY EXPIRATION DATE: Time: :00 a.m. DESCRIPTION OF OPERATIONS Describe type of work done by applicant Incl. Description of most recently completed project: No. Years in Business: COVERAGE AND LIMITS OF LIABILITY Coverages Options Selected Limits/options COMBINED SINGLE LIMITS Bodily Injury and Property Damage Liability SPLIT LIABILITY LIMITS Bodily Injury Liability Property Damage Liability Employer's Non-Ownership 5,000/0,000 5,000/50,000 50,000/00,000 00,000 500,000 750,000,000,000 0,000 5,000 50,000 00,000 Same as Policy Liability Limits 00,000/00,000 50,000/500,000 Hired Car Same as Policy Liability Limits Medical Payments,000,,000, 5,000 Uninsured/Underinsured Motorist Bodily Injury Driver Other Car 5,000/0,000 5,000/50,000 0,000/60,000 50,000/00,000 00,000/00,000 Same as Policy Liability and MP Limits Page of 5
GENERAL INFORMATION - Explain All YES responses Yes No Yes No APPLICANT S INITIALS PRIOR INSURANCE COVERAGE HISTORY Please select one: Less than months - months or more months of Prior Insurance (verification required)* * Attach copy of renewal notification or policy declarations from prior carrier(s) expiring less than 0 days from effective date at binding to qualify for discount AUTO LIABILITY INSURANCE COVERAGE HISTORY (PAST YEARS) Carrier Name Policy Number Prior Insurance Limits Policy Term Dates Total Premium Page of 5
DRIVER LIST Driver # 5 6 7 8 9 0 First VEHICLE INFORMATION Vehicle Description # Name Last Marital Status V.I.N. Date of Birth Yrs. Exp. Driver License # State Lic. Garaging Zip GVW Current Value Usage SR Filing Radius Year: Make: Model: Year: Make: Model: Year Make Model Year Make Model Veh. # Veh. # Veh. # Veh. # Comprehensive Named Perils Collision Uninsured Motorist Physical Damage s/sound Systems (Complete s Section below) Additional Equipment/Modifications (Complete Add l Eqpt Section below) Rental Reimbursement Specified Amount (Ded will be same as vehicle's) Specified Amount (Ded will be same as vehicle's) $0 per day, 600 Max STEREOS/SOUND SYSTEMS or ADDITIONAL EQUIPMENT/MODIFICATIONS Veh. # Veh. # Veh. # Veh. # Vehicle # Item (List), Make/Model, I.D. # Required Cash Value Page of 5
CALIFORNIA UNINSURED MOTOR VEHICLE COVERAGE REJECTION/SELECTION NOTE: If Uninsured Motorist Coverage is NOT to be included the Applicant must sign this waiver. If named-insured is age 7 or under, waiver must also be signed by a parent or legal guardian. Uninsured motorist coverage provides that if you suffer bodily injury or sickness, including death, resulting from an accident with a hit and run driver or a person who does not carry liability insurance, and if he is at fault, you make the claim against your own insurance company for general damages and special damages rather than against the uninsured motorist. You are strongly recommended to purchase this coverage. DELETION OF UNINSURED MOTORIST COVERAGE FROM THIS POLICY The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the applicant to delete the coverage completely or to delete such coverage when a motor vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the 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 or a resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section 580. of the Insurance Code. I have read the above, and agree to the deletion of Uninsured Motorist Coverage. Accepted: Signature of Applicant (Named Inured) Date SELECTION OF REDUCED LIMITS OF UNINSURED MOTORIST BODILY INJURY COVERAGE The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the applicant to agree to provide the coverage in an amount less than that required by Subdivision (m) of Section 580. of the Insurance Code but not less than the financial responsibility requirements. Uninsured motorists coverage insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in Subdivision (p) of Section 580. of the Insurance Code. APPLICANT / BROKER SIGNATURES Accepted: Signature of Applicant (Named Insured) Date Applicant s Signature: I agree all answers to all questions in this Application are true and correct. I understand, recognize, and agree said answers are given and made for the purpose of inducing the Company to issue the policy for which I have applied. I further agree that ALL persons of eligible driving age or permit age who live with me, as well as ALL operators who regularly operate my vehicles and do not reside in my household, are shown above. I agree that my principal residence and place of vehicle garaging is correctly shown above and is in the state for which I am applying for insurance at least 0 months each year. I understand the Company may rescind this policy if said answers on this Application are false or misleading, and materially affect the risk the Company assumes by issuing the policy. In addition, I understand that I have a continuing duty to notify the Company of any changes of: () address; () location of vehicles; () members of my household of eligible driving age or permit age; () operators of any vehicles listed on the policy; or (5) use of any vehicles listed on the policy. I understand the Company may rescind this policy if I do not comply with my continuing duty of advising the Company of any change as noted above. I understand and agree that in connection with my request for a premium quotation and Application for insurance: () the Company may obtain consumer reports which may include a driver history report, credit information, or personal or privileged information from third parties; () such information may be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or required by law; () upon my written request, the Company will inform me if a consumer report was requested and the name and address of the consumer reporting agency that furnished the report; () I may also request access to and correction of information the Company has collected on me; (5) the Company may request and use subsequent consumer reports in updating and renewing any insurance afforded in connection with this Application; (6) the Company will furnish a more detailed explanation of its information practices upon my request; and (7) refusal to authorize the Company to obtain a consumer report may give the Company the right to decline insurance to me. I hereby authorize the Company to obtain consumer reports on me. I agree the named members of my household and all other operators listed under this policy have authorized me to consent on their behalf to all coverages provided herein and to authorize the Company to obtain consumer reports on them for the rating and/or underwriting of the insurance for which I am applying and for any renewal thereof. I agree that a radius restriction will apply when vehicle(s) listed on this application is (are) in commercial use and I have accurately listed each vehicle(s) radius of operation. I agree to pay any additional premium owed if the amount of premium shown is inaccurate for any reason. Page of 5
I have had the liability coverages and limits available for the purchase fully explained to me and have selected the limits shown on the Application. I have had the different policy coverage levels available to me fully explained. I made an informed decision and have selected the policy coverage level shown on the Application. I understand the policy may be rescinded and no coverage provided if my premium down payment or full payment is paid by check, credit card, or debit card and the bank returns said check unpaid or fails to honor the credit charge or debit charge in full. I understand there may be a processing fee imposed on any returned checks. I understand processing fees may be included with my down payment and installment payments, and additional fees may be charged for late payments. I understand my payments are first applied to the fees owed and then to the premium. I understand my producer will receive compensation for this policy in the form of a commission and may from time to time receive other compensation from the Company based on sales and/or profitability. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Agreed Signature of - Applicant Date: Broker s Signature: The undersigned hereby declares that to the best of my knowledge, all information contained herein is correct; that this form was completed with the applicant and then signed by the applicant; and that the initials of the applicant contained herewith were made by the applicant. I also certify that all questions on the application have been asked to and answered by the applicant. Signature of Broker: Broker License No.: Date: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. LOSS PAYEE Vehicle # Loss Payee - (Financial Institution Only) Name and Address ADDITIONAL INTEREST/ADDITIONAL INSUREDS Name and Address 5 6 7 8 9 0 Page 5 of 5