Section I - General Information

Effective Dates of Policy

Phone #:

Insured Name:

Fax #: 

Mailing Address: 

City: 

State: 

Zip: 

 Insured is – Individual: 

Partnership: 

Corp: 

Limited Liability Corp: 

Other: 

Year Business Established: 

Employee ID # (FEIN): 

Description of Insured's Operations: 

Company President/CEO Full Name: 

Date of Birth: 

Residential Address: 

Does President/CEO drive any vehicles:

If Yes, please provide License Number:

Section II - Driver Information

Drivers Full Name	Date of Birth	Date Employed	Marital Status	Drivers Lic. Number/State

Section III – Schedule of Units

Unit#	Year	Make	Model	VIN	Vehicle Value
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Unit#	Principal Location of Garaging (including city, state and zip)	Max. Radius of Operations
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Section IV – Coverage and Limits Requested

Liability Limits: 

Physical Damage: 

Hired/non-owned: 

Personal Injury protection:

If yes, provide details: 

Do any employees or 
subcontractors carry firearms? 

Loss Payable Name and Address (advise which unit(s) this applies to):

List any Additional Insureds to be named and advise what their interest is in your operation:

List any Person or Organization requesting a Waiver of Subrogation, and advise reason for this request: 

I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am also aware that the Insurance Company may inspect my operations.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be subject to civil or criminal penalties.