Form Tcel-5 - Commercial Auto Insurance Application
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3TOPA
Commercial Auto Application
Agent's Name and Address
Insurance Company
This application will not be given consideration unless:
Phone Number
Code
1. It is fully completed and every question is answered;
2. Accompanied by a current MVR for ALL drivers and
Applicant's full name
3. Application is signed personally by the Applicant and Agent.
[ ] Liability and Physical Damage
Policy Requested:
[ ] Physical Damage Only
D.B.A. if any
[ ]
New Business [ ] Renewal of Topa Policy #
Mailing Address - It P.O. Box then give the actual address below
Is the applicant: [ ] An Individual [ ] A Partnership [ ]A Corporation or
[ ] Other - If Other please specify:
City
State
Zip Code
How long has the applicant been in business?
Years
Is this a new venture? [ ] No [ ] Yes if yes, explain past experience.
Phone Number
Name of Contact Person
Describe the business operations of the applicant.
Place of principal garaging. If same as mailing address then write ''SAME''.
Proposed Effective Date
POLICY TERM
NOTE: Coverage cannot be bound until approved by the Company. When approved
the application and payment must be postmarked within 48 hours of the effective date;
[ ] 12 Months
otherwise coverage will be effective at 12:01 A.M. on the date following the postmark
[ ] 6 months
on the envelope.
at 12:01 A.M. Standard Time
GENERAL INFORMATION ALL QUESTIONS MUST BE FULLY ANSWERED!
1. Must the applicant comply with the Motor Carrier Act of 1980?
9. Is there a vehicle maintenance program in place? [ ] No - W hy not?
[ ] No [ I YES - If 'yes' the risk is unacceptable.
[ ] Yes - Explain
2. Does the risk EVER haul hazardous substances, flammables, explosives,
10. Does the applicant ever operate outside the resident State? [ ] No [ ] Yes -
chemicals or acids? [ ] No [ ]Yes - Not eligible
How often and where?
3. Does the applicant operate on a regular route? [ ] No [ ] Yes - List cities and
11. Are any sub-haulers utilized? [ ] No [ ] Yes - What percentage?
destinations.
4. Does the applicant rent or lease vehicles to others?
12. Do other truckers operate under the applicant's filing authority? [ ] No [ ]Yes
[ ]No [ ]Yes - If ''yes'' the risk is unacceptable
5. 15 the applicant under contract or lease to haul for a single firm? [ ] No [ ] Yes -
13. Number of Employees?
Give full name.
6. Are ALL vehicles owned or operated shown on the application? [ ] Yes
14. Do any employees use their own vehicles during the course of employment
[ ] NO - where insured?
on a regular basis? [ ] No [ ] Yes.
15. What are the applicant’s annual gross receipts? $
7. Is the applicant the registered owner of all units listed, except ''unidentified trailers''? [
]Yes [ ] No - explain
8. Any policy or coverage declined, canceled or nonrenewed in the past 3 yrs.
16. Are any vehicles registered or garaged outside of the applicant's resident
[ ]No [ I Yes - explain
State? [ ] No [ ] Yes - explain:
Type of cargo or goods hauled and percentage of each. Be specific -
[ ]
DMV # ___________
FILINGS: [ ] PUC Filing - Your Cert # _________________________________ [ ]ICC # ______________
[]Other: ___________________
NOTE: There is a fully earned fee for each filing, INCLUDING REINSTATEMENT& We must insure ALL vehicles
owned or operated by the applicant to make a regulatory filing.
LIST ALL INSURANCE POLICIES FOR THE PAST THREE YEARS.
Insurance Company
Policy Number
Policy Period Dates
Coverages (BI/PD/COMP/COLL
LIST ALL CLAIMS IN THE PAST 3YEARS
Date of Loss
Type of Loss
Description of Loss
Amount Paid
Driver
TCOM-A (11/01) PDF FILE
page 1
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