Form Tcel-5 - Commercial Auto Insurance Application (Page 3 of 3) in pdf

DRIVER INFORMATION - LIST ALL PART-TIME, FULL-TIME OR OCCASIONAL DRIVERS- ALL DRIVERS MUST BE LISTED)

Does applicant review MVR's prior to hiring?

YES

Does applicant require current D.O.T. physicals on all drivers?

YES

Driver #

Full name as on Drivers License

Date of Birth

Year Experience

Driver's License Number

State

Driver #

Date

List ALL violations, convictions and accidents in the past 3 years . Provide proof on no -fault accidents

Accidents or Losses

APPLICANT QUESTIONNAIRE - TO BE COMPLETED AND INITIALED IN THE APPLICANT'S HANDWRITING

Have all drivers who may operate an insured vehicle on an occasional, part -time or full time basis been listed in the

[ ]

Yes [ ]No explain below

driver section? This includes family members who may operate a listed vehicle.

Initials:

Are all owned or operated (including vehicles under a 30 day or longer lease) commercial vehicles listed in the vehicle

[ ]

Yes [ ]No explain below

section?

Initials

Are all vehicles listed on the application which are operated under the insured's regulatory filing?

[ ] Yes [ ] No - explain below

Initials

Explain:

< = = Explain any ''no'' answers

PREMIUM SUMMARY

This is only a summary of the premium and fees due. The premium

Total Premium for All Vehicles

breakdown by coverage and vehicle will be provided to you under a

Hired & Non-Owned Auto Premium - if any

separate quote sheet. Do not sign this application until you have

reviewed the actual quote sheet details.

Filling Fees -if any

Fully Earned Policy Fee

I have reviewed the actual quote: Applicant's Initials: X _ _ _ _ _ _ _ _ _ _.

Total Premium Due

AMOUNT REMITTED WITH APPLICATION

APPLICANT AND AGENT SIGNATURES. THIS MUST BE SIGNED OR APPLICATION WILL BE REJECTED.

I hereby declare and warrant that to the best of my knowledge the statements made on the application are true and complete and that these statemen ts are made as an

inducement to the Company to issue the insurance policy for which I am applying. I agree that such policy shall be null and void if my premium payment check does not clear

the bank when initially presented. I acknowledge that a $10.00 change will apply for all checks returned due to insufficient funds

I understand a routine investigation may be made as to my insurability, including requesting a copy of my motor vehicle record from the Department of Motor vehicles,

character, general reputation, personal characteristics, credit history, condition of vehicles and their use. Upon written re quest, additional information as to the nature and

scope of the report, if one is made, will be provided.

I further declare that I have not had an accident or loss in the last 72 hours and that I am the legal and/or registered owne r of all vehicles.

APPLICANT'S SIGNATURE: ____________________________________________ Time: ________________ AM - PM Date ___________________________________

I warrant and certify that all information contained herein is correct to the best of my knowledge, that this application was completed and then signed by the insured/applicant,

that a completed copy hereof has been given to the insured/applicant, and that I am retaining a duplicate copy.

AGENT'S SIGNATURE: ________________________________________________ Time: ___________ AM - PM Date: ____________________________________

DRIVER EXCLUSION

It is hereby understood and agreed that all coverages and OUR obligation to defend under this policy shall not apply nor accrue to the benefit of any INSURED or any third

party claimant while any VEHICLE or MOBILE EQ UIPMENT described in the policy or any other VEHICLE or MOBILE EQUIPMENT, to which the terms of the policy are

extended, is being driven, used or operated by any person designated below.

The driver exclusion shall be binding upon every INSURED to whom such policy or endorsements provisions apply while such policy is in force and shall conliritie to be

binding with respect to any continuation, renewal or replacement of such policy by the Named Insured or with respect to any reinstatement of such policy within 30 days of any

lapse thereof. This DRIVER EXCLUSION provisions shall conform State statutes and laws.

Name of Person Excluded

Reason For Exclusion

Date of Birth or Social Security #

___________________________________________

______________________________________

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