127 Business Auto Section

Applicant Name*
Effective date*
Expiration date*
COVERAGES/LIMITS:
Driver 1
Name*
Sex*
Marital status*
Date of birth*
Years experience*
Years license*
State license*
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 2
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 3
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 4
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 5
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 6
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 7
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 8
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
Driver 9
Name
Sex
Marital status
Date of birth
Years experience
Years license
State license
Date hire
Broaden no fault
Doc
Use vehicle number
Percent use
General Information:
With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?*
Explain
Do over 50 percent of the employees use their autos in the business?*
Explain
Is there a vehicle maintenance program in operation?*
Explain
Are any vehicles leased to others?*
Explain
Are any vehicles customized, altered or have special equipment?*
Explain
Are ICC, PUC or other filings required?*
Explain
Do operations involve transporting hazardous material?*
Explain
Any hold harmless agreements?*
Explain
Any vehicles used by family members?*
If so, please identify
Does the applicant obtain MVR verifications?*
Explain
Does the applicant have a specific driver recruiting method?*
Explain
Are any drivers not covered by workers compensation?*
Explain
Any vehicles owned but not scheduled on this application?*
Explain
Any drivers with moving traffic violations?*
Explain
Has agent inspected vehicles?*
Explain
Additional Interest/Certificate Recipient:
Interest?
Rank
Interest name
Address
City
State*
Zip
Reference number
Certificate required?
Item description
Interest in vehicle item number
Interest in scheduled item number
Interest in other
Remarks:
Vehicle Description:
Vehicle 1 information
Year*
Make*
Model*
Body type*
Vehicle identification number(V.I.N.)*
Vehicle type
Sym/Age
Cost new ($)
Vehicle 1 where garaged
Address
City
State*
Zip
License state
Territory
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 2 information
Year*
Make
Model
Body type
Vehicle identification number (V.I.N.)
Vehicle Type
Sym/Age
Cost new ($)
Vehicle 2 where garaged
Address
City
State*
Zip
License state
Territory
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 3 information
Year*
Make
Model
Body Type
V.I.N.
Vehicle Type
Sym/Age
Cost new ($)
Vehicle 3 where garaged
Address
City
State*
Zip
License state
Terr
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 4 information
Year*
Make
Model
Body type
Vehicle identification number(V.I.N.)
Vehicle type
Sym/Age
Cost new ($)
Vehicle 4 where garaged
Address
City
State*
Zip
License state
Territory
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 5 information
Year*
Make
Model
Body type
Vehicle identification number (V.I.N.)
Vehicle type
Sym/Age
Cost new ($)
Vehicle 5 where garaged
Address
City
State*
Zip
License state
Territory
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 6 information
Year*
Make
Model
Body type
Vehicle identification number (V.I.N.)
Vehicle type
Sym/Age
Cost new ($)
Vehicle 6 where garaged
Address
City
State*
Zip
License state
Territory
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 7 information
Year*
Make
Model
Body type
Vehicle identification number (V.I.N.)
Vehicle Type
Sym/Age
Cost new ($)
Vehicle 7 where garaged
Address
City
State*
Zip
License state
Terr
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 8 information
Year*
Make
Model
Body type
Vehicle identification number (V.I.N.)
Vehicle type
Sym/Age
Cost new ($)
Vehicle 8 where garaged
Address
City
State*
Zip
License state
Terr
Gross vehicle weight/Gross capacity weight
Class
Sic
Factor
Seat capacity
Radius
Farthest term
Drive to work/school
Use
Coverages
Collision Deductible ($)
Comprehensive Deductible ($)
Spec C of L Deductible ($)
Vehicle 9 information
Year*