Form Tcel-5 - Commercial Auto Insurance Application Page 2
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1
2
3Coverages & Limits of Liabililty (in thousands)
Per Accident
[ ] Liability
Bl: $
Per Person $
[ ] Uninsured Motorist - PD: $
Per Accident
Split Limits
PD$
Per Accident
California Only and cannot have Collision
[ ]
[ ] Liability
S
Combined Single Limit
Each Person $
Each Acct.
Underinsured Motorist $
[ ]
[ ] Medical Payments
$
Each Person
Hired Auto Liability Cost of Hire = $ __________
[ ] Uninsured Motorist - BI S
Per Person
$
Per Accident
[ ] Non-owned Auto Liab. Number of Employees =
NOTE: MEd. Pay, UM-Bl. UM-PD and UIM- BI coverage may be rejected depending on your state's laws. Please attach your States acceptance/rejection form.
[ ]
Liability Deductible: BI = $
PD = $
A deductible may be imposed by the Company even it not requested.
VEHICLE INFORMATION - COMPLETE FOR EACH VEHICLE TO BE INSURED. USE ADDITIONAL APPLICATIONS IF NECESSARY!
Unit # 1
How is this unit used?
No. of trips per day?
Year
Manufacturer and Model
Body Type
Complete Serial Number
Current Replacement Value
GVW or Gallons
Use
Maximum Radius
Anti-lock brakes
4 Wheel Drive
Spec. Perils Ded.
Coll. Ded
On-Hook Liability
[ ] Comm [ I Serv
[ ] 100 [ ] 200
[ ] Yes
[ ] No
[ ] 25,000 [ ] 50.000
[ ] Retail [ ] Ultra
[ ] 300 [ ] 500
[ ] No
[ ] Yes
Deductible
[ ]Personal [ ] Hvy
Miles
[ ]500 [ ] 1000
Garage Location
including zip code:
Loss Payee
Name & Address
Additional Insured
Name & Address
Unit # 2
How is this unit used?
No. of trips per day?
Year
Manufacturer and Model
Body Type
Complete Serial Number
Current Replacement Value
GVW or Gallons
Use
Maximum Radius
Anti-lock brakes
4 Wheel Drive
Spec. Perils Ded.
Coll. Ded
On-Hook Liability
[ ] Comm [ ] Serv
[ ] 100 [ ] 200
[ ] Yes
[ ] No
[ ] 25,000 [ ] 50.000
[ ] Retail [ ] Ultra
[ ] 300 [ ] 500
[ ] No
[ ] Yes
Deductible
[ ]Personal [ ] Hvy
Miles
[ ]500 [ ] 1000
Garage Location
including zip code:
Loss Payee
Name & Address
Additional Insured
Name & Address
Unit # 3
How is this unit used?
No. of trips per day?
Year
Manufacturer and Model
Body Type
Complete Serial Number
Current Replacement Value
GVW or Gallons
Use
Maximum Radius
Anti-lock brakes
On-Hook Liab
Spec. Perils Ded.
Coll. Ded
4 Wheel drive
[ ] Comm [ ] Serv
[ ] 100 [ ] 200
[ ] Yes
[ 125,000 [ ] 50,000
[ ]
Yes
[ ] Retail [ ] Ultra
[ ] 300 [ ] 500
[ ] No
Deductible:
[ ]
No
[ ]Personal [ ] Hvy
Miles
[ ] 500 [ ] 1,000
Garage Location
including zip code:
Loss Payee
Name & Address
Additional Insured
Name & Address
Unit # 4
How is this unit used?
No. of trips per day?
Year
Manufacturer and Model
Body Type
Complete Serial Number
Current Replacement Value
GVW or Gallons
Use
Maximum Radius
Anti-lock brakes
On-Hook Liab
Spec. Perils Ded.
Coll. Ded
4 Wheel drive
[ ] Comm [ ] Serv
[ ] 100 [ ] 200
[ ] Yes
[ 125,000 [ ] 50,000
[ ]
Yes
[ ] Retail [ ] Ultra
[ ] 300 [ ] 500
[ ] No
Deductible:
[ ]
No
[ ]Personal [ ] Hvy
Miles
[ ] 500 [ ] 1000
Garage Location
including zip code:
Loss Payee
Name & Address
Additional Insured
Name & Address
page 2
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