FLORIDA COMMERCIAL INSURANCE APPLICATION NON-FLEET · INSURANCE APPLICATION NON-FLEET (Commercial...

FLORIDA COMMERCIAL INSURANCE APPLICATION

NON-FLEET (Commercial Auto, General Liability, Inland Marine/Cargo)

A-101 FL (10-2013) 1

Canal Insurance Canal Indemnity Proposed Effective Date:______________ Expiration Date: _______________ New Policy No: __________________________ Renewal Policy No:____________________

GENERAL INFORMATION Individual LLC Partnership Corporation Other ________________________________

General Agency: Name ________________________ Code ___________ Producing Agency: Name ________________________ Code ___________

Applicant Name

Company Name (DBA1) (if any)

Phone #

Cell Phone # US DOT # Federal ID # Month/Year Current Operations Began

Location of the Business or Physical Address, if different

City State Zip

Location is:

Inside City Limits Outside City Limits

Company Website

Mailing Address

City State Zip

Safety Director Safety Director Phone # Operations Director Name

Operations Director Phone #

Safety Director Email Address Years in Current Position Operations Director Email Address Years in Current Position

Safety Director Address Operations Director Address

FOR VIRGINIA APPLICANTS ONLY: Read your policy. The policy of insurance for which this application is being made, if issued, may be cancelled without cause at the option of the insurer at any time in the first 60 days during which it is in effect and at any time thereafter for reasons stated in the policy. MARYLAND NOTICE OF UNDERWRITING PERIOD ADVISORY NOTICE TO POLICYHOLDERS: We are notifying you that the policy you have just agreed to purchase is subject to a 45 day underwriting period beginning on the effective date of your coverage. Your coverage may be cancelled during the underwriting period if your risk does not meet our underwriting standards. If we decide to cancel the policy, we will send you a written notice of cancellation advising you of the reason(s) for the cancellation and the date on which your policy will be cancelled. Your premium may be recalculated during the underwriting period due to discovery of a material risk factor. If we recalculate the premium, we will send you a written notice of recalculation of premium advising you of the amount of and reason for the recalculated premium. FOR SOUTH CAROLINA APPLICANTS ONLY: THE INSURER CAN CANCEL THIS POLICY FOR WHICH YOU ARE APPLYING WITHOUT CAUSE DURING THE FIRST 90 DAYS. THAT IS THE INSURER'S CHOICE. AFTER THE FIRST 90 DAYS, THE INSURER CAN ONLY CANCEL THIS POLICY FOR REASONS STATED IN THE POLICY.

OWNER / PRINCIPAL / PRESIDENT Name

Title

SSN2

Home Address Apt #

City

State Zip Business Phone

Range of Transport: Interstate Intrastate

Brokerage: Do you have Brokerage Authority? ____ Under the same name? ____. Do you broker both exempt & non-exempt loads? ____ If yes, % of brokerage under same name ____%.

Percent of Loads:

(Local) 0 – 150 Miles ______ (Intermediate) 151 – 300 Miles ______ (Long Haul) 301 – 500 Miles ______ (Long Haul) 501 Miles + _________ Longest Trip One Way _____________ Miles Annual Miles Driven _________________ Miles

1 DBA: Doing Business As 2 SSN: Social Security Number 3 PPT: Private Passenger Type

DESCRIPTION OF OPERATIONS

Bus

ines

s C

lass

Trucking For Hire – Exempt Trucking for Hire – Nonexempt Manufacturer Retailer Agriculture Mining Wholesale Distributer Service Construction Forestry

Ope

ratio

ns

Auto – Boat Haulers Commercial Use – Truck Container/Intermodal Contractors Courier/Specialized Del. Drive-away Dry Bulk/Farm Products Dry Van/Box Dry Van – Doubles Dump Dump-Coal Flatbed Livestock Log or Pulp Mobile Home Non-Trucking Refrigerated PPT3 – Corporate Owned Service Truck Special Type Operations Tanker-Fuel Tanker – Liquids/Comp. Gases Towing & Recovery Waste/Garbage Other ____________



A-101 FL (10-2013) 2

LIST CITY DESTINATIONS BELOW 1.

2. 3. 4.

OPERATIONS BEYOND 300 MILES RADIUS: Identify Metropolitan Areas Traveled Through Or Into Atlanta

Cleveland Jacksonville Milwaukee Orlando Salt Lake City Balt-Washington

Dallas/Ft Worth Kansas City Minneapolis/St Paul Philadelphia San Diego Boston

Denver Little Rock Nashville Phoenix San Francisco Buffalo

Detroit Los Angeles New Orleans Pittsburgh Seattle Charlotte

Hartford Louisville New York City Portland, OR Tampa Chicago

Houston Memphis Oklahoma City Richmond Tulsa Cincinnati Indianapolis Miami Omaha St. Louis _____________

Alabama, Mississippi, Louisiana

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Delaware, Maryland, New York, New Jersey, Pennsylvania

Florida, Georgia, North Carolina, South Carolina, Virginia

Cities other than above or regular routes ____________________________________________________________________________________

Top Customers: 1. ______________________________ _____ % Load 2. ______________________________ _____ % Load 3. ______________________________ _____ % Load

Commodity % of Loads Maximum Value Commodity % of Loads Maximum Value

Do you sign contracts with shippers that give the shipper the right to determine cargo salvage values or declare cargos a total loss regardless of actual damage in the event of a loss? If yes, attach a copy of the contract.

PAYMENT OPTIONS

Annual Policy: Full Payment to Company Company Payment Plan ______ % Down payment _____ # of installments

Financed through outside Premium Finance Company with full payment to Canal (no double financing permitted – attach contract)

Continuous Until Cancelled Policy (Escrow deposit and monthly billing will be required.) ______ % Deposit

FILINGS Filings Requested Motor Carrier # / Cert. # Applicant’s Name and Address Exactly As It Appears On Each Permit

Liability BMC 91X

Liability – Form E ____State

Oversized/Overweight ____State

Hazardous ____State

Intermodal

Cargo – Form H ____State DMV ____State SR 22 – If yes explain Other __________________ Please note: The Federal Motor Carrier Safety Administration (FMCSA) and/or state agencies require a minimum 36 day notice of cancellation on all policies that have a

MCS-90 or other filings.

LIENHOLDER AND/OR PAYEE INFORMATION UNIT # NAME ADDRESS

1

2 3

NON-OWNED TRAILERS

1

2 3

CERTIFICATE OF INSURANCE NAME MAILING ADDRESS

COMMODITIES TRANSPORTED



A-101 FL (10-2013) 3

QUESTIONNAIRE YES NO

1. Is all equipment operated under the applicant’s authority scheduled on the application? If no, attach explanation.

2. Is all owned equipment scheduled on this application? If no, attach explanation.

3. Do you lease your vehicles to others? If yes, who must provide liability coverage? You Lessee

4. Do you hire other motor carriers or owner-operators to haul for you? If yes, complete question below, complete Hired Autos Application Supplement and attach copy of lease agreement. If no, skip to question #5.

A. On what basis are they leased? Permanent Basis Temporary/Trip Basis

B. Provide annual cost of hire or # of trips _______________________

_______________________

C. Are vehicles leased with driver?

Yes No

Yes No

D. Are leased vehicles included in this application for insurance?

(1) If yes, do you require leased vehicle owners to purchase non-trucking liability coverage?

Yes No

Yes No (2) If no:

a. Is there a written lease agreement stating the lessor will provide primary auto liability coverage while leased to you?

Yes No

Yes No

b. Limit of Liability required

$

$ c. Do you secure evidence the lessor has primary auto liability coverage?

Yes No

Yes No d. Does the lease state that the lessor agrees to provide you with 30 days advance notice if

their insurance coverage is being cancelled or reduced?

Yes No

Yes No

5. Do you pull doubles?

6. Do you haul intermodal containers?

7. Is any portion of your operation seasonal? If yes, explain. __________________________________________________

8. Do you use any team, hot seat, slip seating or relay driver operations?

9. Do you allow passengers other than company employees? If yes, attach copy of passenger program or explain program (frequency, requirements), etc.

10. Do you operate more than one terminal? If yes, provide the following

LOCATION(S) # UNITS ADDRESS, CITY, STATE

11. Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged? If yes, and need Liability Coverage, complete Mobile Equipment Supplement.

12. Do you require use of escort vehicles? If yes and escort vehicles are not included in this application for insurance, provide the name of the insurance carrier, policy number and auto liability limits. If yes and escort vehicles are included in this application, drivers of escort vehicles should be listed in the Driver Information Section.

13. Do you haul oversized, overweight or hazardous loads? If yes, attach explanation. 14. For Non-Trucking accounts, does the insured lease to other companies? If yes, what is the DOT # of the other entity? _____________

VEHICLE INFORMATION

UNIT

# MODEL YEAR MAKE, MODEL & UNIT TYPE VIN 4 RADIUS GVW or GCW5 STATED

VALUE OWNED = O LEASED = L

GAP6 Coverage

(Y/N)

Is garaging address same as

physical? (Y/N)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

* Power Unit: Tractor or Truck Trailers: Flatbed, Dry Van, Refrigerated, Dump Belly, Dump Hydraulic, Auto or Livestock

4 VIN: Vehicle Identification Number 5 GVW or GCW: Gross Vehicle Weight or Gross Combination Weight 6 GAP: Guaranteed Auto Protection



A-101 FL (10-2013) 4

Please complete this section for vehicles with different ownership or different garaging addresses.

Name and Address of vehicle owners other than the named insured (owner 2, 3 & 4 listed below) Unit

# Name of Owner *Ownership Type Mailing Address

* Please enter the owner type by entering the corresponding number and/or letter. 1. Owned by Named Insured. 2. Owned by Leasing Company (long term lease without a driver), 3. Owned by Owner Operator (leased with driver). 4. Owned by Employee of Named Insured (officer). Please note that coverage for owners might not be afforded if this section is not completed.

For Liability Coverage, if a unit is not garaged at the physical address of the applicant, please list the garaging addresses for each unit. Unit # Street Address

City State Zip County

Unit # Street Address


ADDITIONAL UNDERWRITING INFORMATION In the past five (5) years, have any drivers been convicted of any of the following? Yes No Leaving the scene of an accident or a hit and run, any felony conviction which involves a motor vehicle, driving while license is suspended or revoked in a commercial vehicle, DUI or DWI. If yes, please provide driver name, conviction date and details: _________________________________________________________________________

In the past three (3) years, have any drivers been convicted of any of the following? Yes No Negligent homicide, unlawful use of vehicle, speed contest or racing, reckless driving, or speeding twenty miles or more over the speed limit. If yes, please provide driver name, conviction date and details: _________________________________________________________________________

For Kansas applicants only: Convictions for exceeding a maximum posted speed limit of 30 to 54 MPH by six MPH or less or exceeding a maximum posted speed limit of 55 to 70 MPH by 10 MPH or less shall not be considered by any insurance company in determining the rate charged for any automobile liability policy.

TRUCKERS GENERAL LIABILITY COVERAGE YES NO

Do you haul bulk fuel?

Do you repair or service vehicles of others?

Do you have dogs at premises? (see exclusion endorsement)

Do you or anyone else who is an employee carry a firearm to work? (see exclusion endorsement) Do you generate income from other activities besides the operation of the trucks? Do you want to add Contractual Liability Do you want to add mis-delivery of goods Coverage? Do you have fuel storage containers on premises?

Please list all mobile equipment owned by the applicant, if any (i.e. forklift, backhoe, mobile crane, etc.) Please list all premises owned or rented

Street Address


Description of any other operations being conducted by this applicant?

ADDITIONAL/DESIGNATED INSUREDS FOR AUTO LIABILITY OR TRUCKERS GENERAL LIABILITY NAME MAILING ADDRESS *TYPE OF ADDITIONAL INSURED

* Please enter each desired additional/designated insured by entering the corresponding number and/or letter: Auto Liability Additional Insureds: 1. Designated Additional Insured, 2. Intermodal, 3. Additional Insured Waiver Rights Recovery. General Liability Additional Insureds: A. Controlling Interest, B. Designated Person or Organization, C. Managers or Lessors of Premises, D. Mortgagee, E. Owners, Lessees or Contractors, F. Co-owner of Insured Premises, G. Vicarious Liability of Owners, Lessees or Contractors.



A-101 FL (10-2013) 5

INSURANCE HISTORY AND LOSS EXPERIENCE Provide the following insurance and loss information for the current year plus at least four (4) full prior policy years. HAS ANY INSURANCE COMPANY CANCELLED OR NONRENEWED YOUR POLICY IN THE LAST FOUR (4) YEARS? (Missouri Applicants – Do not answer this question.) Yes No If Yes, explain. _________________________________________________________________________________

Policy Insurance Policy Liability Phys Dam Cargo General Liability

Term Company Number # Loss Amount # Loss Amount # Loss Amount # Loss Amount

Please enter the # of claims over $100,000: _____________

Please enter the dollar amount for claims over $100,000: ___________________

EXPERIENCE INFORMATION: Furnish currently valued (must be value dated within the last 3 months) insurance company produced detailed loss and experience auto liability, physical damage and cargo loss runs for current year plus at least four (4) full prior policy years. Describe any claim with payment or reserves over $25,000:_________________________________________________________________________________________ NOTICE FOR MARYLAND APPLICANTS: Canal’s acceptance of this application is contingent upon the consideration of the applicant’s claims history. If accepted, your claims history will also be considered in determining if the policy should be cancelled or non-renewed.

DRIVER INFORMATION List all individuals that will be allowed to drive vehicles requested to be covered. Report all new drivers immediately to your agent.

Driver’s Name DOB7 Marital Status* Gender License Number

1st Yr CDL8

Issued

Social Security Number

State Years Driving Similar Equip Date of Hire

*if the Driver is in a legally recognized Civil Union, answer “Married” to Marital Status.

DRIVER INFORMATION continued List all individuals that will be allowed to drive vehicles requested to be covered. Report all new drivers immediately to your agent.

# Convicted Violations/Accidents in the Past 3 Years

Driver’s Name

Minor Major Accidents # Convicted

Violations Past Year

7 DOB: Date of Birth 8 CDL: Commercial Driver’s License



A-101 FL (10-2013) 6

DRIVER HIRING, TRAINING AND SAFETY 1. Which of the following is part of your driver screening/hiring process:

Employment Background Check Pre-employment Drug Test Criminal Background Check Road Test Motor Vehicle Record (MVR) review Pre-employment Screening Program (PSP) Report for FMCSA9 Behavioral/ Integrity Testing Physical Abilities Testing

2. Which of the following is part of your driver performance management process:

Annual review of driver’s driving record (MVR) Review of electronic engine data Periodic review of driver and vehicle out of service violations. (SafeState/CSA2010 Reports) Incentives for violation-free and accident-free driving Are Owner Operators subject to Motor Carrier Maintenance Programs, i.e. EOBR10/Qualcomm Formal corrective action procedures. If so, please attach. Periodic review of accidents/incidents Driver safety training? Description of Program ________________________________ Are units governed? If so, what limit __________? Formal Written Hiring Standard. If so, please attach.

3. Do you adhere to a written vehicle inspection and maintenance program? Yes No If yes, describe or attach program. _______________________________________________________________________________________________________________________________

9 FMCSA: Federal Motor Carrier Safety Administration 10 EOBR: Electronic On-Board Recorder



A-101 FL (10-2013) 7

COVERAGES

AUTO LIABILITY LIMITS: $ ______________________ Combined Single Limits LIABILITY FOR NONTRUCKING USE Leased to: _____________________________________________________

LIMITS: $ ______________________ Combined Single Limits HIRED AUTO LIABILITY Cost of Hire ____________________ NON-OWNED Is the account a Service or Charitable Organization? Yes No # of Power units under agreement ___________ MEDICAL PAYMENTS Limits _______________________ Property Protection (Michigan Only) Property Damage Buyback (Michigan Only) Medical Expense (Virginia Only) Income Loss Benefits (Virginia Only) New York Spousal Liability Coverage (New York Only)

PHYSICAL DAMAGE (Please refer to Vehicle Information Section for Stated Amount values by Vehicle.)

Comprehensive $__________Deductible Collison $__________Deductible Specific Cause of Loss (SCoL) $__________Deductible TOWING Amount of Coverage $_____________. RENTAL REIMBURSEMENT Amount Per Day $__________ for 30 days. ROADSIDE SERVICE TRAILER INTERCHANGE Provide a Copy of Agreement

# of Power units under agreement ___________ Maximum trailer value $____________ # trailer days per power unit ______________ NON-OWNED TRAILER LIMIT Limits _______________________ Provide a Copy of Agreement

ENHANCED PHYSICAL DAMAGE Standard Preferred

HIRED AUTO PHYSICAL DAMAGE Complete and Attach Supplement

CARGO Limit $___________________ $___________________Deductible (Same for all vehicles with Cargo Coverage) OPTIONAL CARGO COVERAGES: (Check all that apply)

Refrigeration Breakdown – $2,500 deductible applies Earned Freight Increase to $________ ($1,000 included) Debris Removal Increase to $____________________ ($25,000 Included)

UNINSURED/UNDERINSURED MOTORIST AND PERSONAL INJURY PROTECTION OPTIONS Complete and Attach Supplements (ACORD 61 FL, ACORD 62 FL, and ACORD 64 FL) TRUCKERS GENERAL LIABILITY COVERAGE SELECTION This is for businesses solely involved in “For-Hire” transportation of property.

Desired Aggregate Limits – please select one $1,000,000 $2,000,000 Each Occurrence $1,000,000 (included) Employers Liability (Stop Gap) Coverage – Applicable only in ND, OH, WA and WY. Please select either yes or no. Yes No $1,000,000 Bodily Injury by Accident – each accident $1,000,000 Bodily Injury by Disease – each employee $1,000,000 Bodily Injury by Disease – each policy



A-101 FL (10-2013) 8

FRAUD STATEMENTS ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. ALASKA and VERMONT: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information may be prosecuted under state law. DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. ARKANSAS, LOUISIANA, RHODE ISLAND and WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ARIZONA: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CALIFORNIA: For you protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading information is guilty of a felony. INDIANA: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. KANSAS: Any person who, knowingly and with intend to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.



A-101 FL (10-2013) 9

MAINE, TENNESSEE, VIRGINIA and WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits. MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in RSA 638:20. NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person, who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. OHIO: 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 is guilty of insurance fraud. OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law. PENNSYLVANIA: GENERAL: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. TEXAS: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. UTAH: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed by false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.



A-101 FL (10-2013) 10

MVR AND CREDIT REPORT ACKNOWLEDGEMENT I authorize Canal Insurance Company and/or Canal Indemnity to obtain a copy of any Motor Vehicle Report for rating/underwriting the insurance for which I have applied. DISCLOSURE: In connection with the application for commercial automobile insurance, we may review a credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of the insurance score. Your credit report/credit based insurance score will not be used other than the underwriting of the commercial automobile insurance for which you have applied. Under no circumstances can the credit-based insurance score, the lack thereof, or the refusal to authorize the obtaining of a credit report or a credit-based insurance score is a factor in determining your eligibility for commercial automobile, including cancellation or nonrenewal, if a policy is ultimately issued. I authorize Canal Insurance Company and/or Canal Indemnity to obtain a credit report, including but not limited to a credit based insurance score based on personal information provided. This authorization is valid for future reports obtained for renewal policies with Canal. ___________________________________________ ____________________________ Applicant Signature Date For Arkansas Applicant Only: I hereby authorize Canal Insurance Company and/or the Producing Agent to obtain from the Arkansas Office of Driver Services a copy of my Motor Vehicle Report for the use in rating and/or underwriting the insurance for which I do hereby apply and any renewal thereof. I understand that in obtaining a Motor Vehicle Report a consumer reporting agency may be used by the insurer and I do hereby authorize such use. I hereby certify that the named drivers under this policy (names specified on application and/or drivers hired during the term of this insurance) have or will have authorized me to consent on their behalf for the insurer to obtain Motor Vehicle Reports for rating and/or underwriting; and I hereby certify that the information above is true and agree that a misrepresentation of any of the facts by me will constitute reason for the company to void or cancel any policy issued on the basis of this application, and will hold the company harmless for the action taken. I also agree that if a policy is issued pursuant to this application, the application and any restrictive and/or Exclusion Endorsement Text, which is included on the application and signed by me, shall become a part of the policy.

ACKNOWLEDGEMENT AND SIGNATURE I hereby acknowledge that the information contained in this application is true and agree that any intentional misrepresentation of any of the facts by me will constitute reason for the Company to cancel any policy issued on the basis of this application, and will hold the Company harmless for the action taken. I also agree that if a policy is issued pursuant to this application, the application and any elections or rejections, which are included with the application and signed by me, may be relied upon by the Company as accurate and shall become a part of the policy. I understand that the coverage selection and limit choices indicated herein will apply to all future policy renewals, continuation and change unless I, or my agent, notify Canal Insurance Company otherwise in writing. Signature of APPLICANT ________________________________ Type or Print Applicant Name ________________________________ Title or Relationship to Applicant ________________________________ Date and Time Application Completed ________________________________ Requested Effective Date and Time ________________________________ Phone # of Applicant ________________________________ Fax # of Applicant ________________________________

Signature of AGENT of the Applicant ________________________________ Agency Name ________________________________ Address of Agency ________________________________ ________________________________ Phone # of Agency ________________________________ Fax # of Agency ________________________________ Agent Name ________________________________ Agent License Number ________________________________ Canal General Agent Use Only Date and Time Bound ________________________________

SUPPLEMENTAL QUESTIONNAIRE Canal Insurance Canal Indemnity Proposed Effective Date:______________ Expiration Date: _______________ New Policy No: __________________________ Renewal Policy No:____________________

DESCRIPTION OF OPERATIONS

Video Based Technology Type:

None DriveCam SmartDrive GreenRoad Other_______________________

Safety Technology Type:

Electronic Logging Device Disc Brakes Tractor; Percentage of Fleet: _______ Disc Brakes Trailer; Percentage of Fleet: ________ Collision Avoidance; Type: ______________________ Lane Departure; Type: ______________________ Web Based Safety Training; Type: ______________________ Other Safety Training; Type: ________ GPS Tractor: ______________________ GPS Trailer: ______________________ Other: ______________________

COVERAGES – Please answer the following additional questions as applicable to desired coverages

Truckers General Liability

Any General Liability losses in the past 36 months? Yes No Does insured have any permanently attached mobile equipment? Yes No Does insured own a tank farm? Yes No Does insured own or operate other business activities? Yes No If yes, please describe: _________________________________________________ Does insured have a warehouse? Yes No Non-Owned Auto Liability

Number of Employees: _____ Non-Owned Trailer Collision

Number of power units covered by liability that pull non-owned trailers: _____ Number of power units covered by physical damage that pull non-owned trailers: _____ Hired Auto Collision

Deductible: $500 $1,000 $2,500 $5,000 $10,000

Stated Value per Auto Limit: ________ Cost of Hire: ________ Designated Shipper (Attach separate page as needed)

Shipper Name % Annual Revenue Limit for Shipper

Complete the following page if purchasing Garagekeepers Coverage

SUPPLEMENTAL QUESTIONNAIRE GARAGEKEEPERS SELECTION – Please complete the following if purchasing Garagekeepers Coverage

Address: _______________________________________ _______________________________________ County:____________________________

Primary Use: Office Terminal Garaging Other ________________

Garagekeepers OTC

Limit: ___________________

Type: Comprehensive SCOL

Deductible:

100/500 250/1000 500/2,500 1,000/5,000 2,500/10,00 5,000/25,000

Rating Basis:

Legal Liability Direct (Primary) Direct (excess)

Garagekeepers Collision

Deductible: 100 250 500 1,000 2,500 5,000

FLORIDA COMMERCIAL AUTO SUPPLEMENT

SELECTION / REJECTION OF UNINSURED MOTORIST COVERAGE

YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY.

SELECT FROM THE FOLLOWING AND COMPLETE SECTIONS A AND C, OR B, AS INDICATED:

POLICY WILL INCLUDE SPECIFICALLY INSURED OR IDENTIFIED MOTOR VEHICLE(S) REGISTERED OR PRINCIPALLY GARAGED IN FLORIDA. SECTION A BELOW AND SECTION C ON PAGE 3, MUST BE COMPLETED.

UNINSURED MOTORIST COVERAGE IS DESIRED FOR OTHER THAN SPECIFICALLY INSURED OR IDENTIFIED MOTOR VEHICLE(S) REGISTERED OR PRINCIPALLY GARAGED IN FLORIDA. COMPLETE SECTION B ON PAGE 2. NON-STACKED COVERAGE WILL AUTOMATICALLY BE APPLIED.

SECTION A

Uninsured Motorist Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or death resulting therefrom. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the policy. For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the Bodily Injury Liability Limits or Combined Single Limit for Liability are less than your damages.

Florida law requires that automobile policies include Uninsured Motorist Coverage at limits equal to the Bodily Injury Liability Limits (Split Limits) or Combined Single Limit for Liability Coverage in your policy unless you select a lower limit offered by the company, or reject Uninsured Motorist Coverage entirely.

Please indicate below whether you desire to entirely reject Uninsured Motorist Coverage, whether you desire this coverage at limits equal to your Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage, or whether you desire this coverage at limits lower than the Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage of your policy.

NEW CUSTOMERS - IF YOU DO NOT ELECT ANY OF THE BELOW, YOUR POLICY WILL INCLUDE UNINSURED MOTORIST LIMITS EQUAL TO YOUR BODILY INJURY LIABILITY LIMITS OR COMBINED SINGLE LIMIT FOR LIABILITY COVERAGE.

RENEWAL / EXISTING CLIENTS - IF YOU HAVE PREVIOUSLY COMPLETED AND SIGNED AN ELECTION OF COVERAGE FORM AND DO NOT WISH TO CHANGE YOUR ELECTION, NO FURTHER ACTION IS REQUIRED AND SUCH ELECTION WILL BE REFLECTED ON YOUR MOST CURRENT DECLARATION PAGE(S). IF YOU CHANGE YOUR BODILY INJURY LIABILITY LIMITS OR COMBINED SINGLE LIMIT FOR LIABILITY COVERAGE, WE MUST MATCH YOUR UNINSURED MOTORIST LIMITS TO YOUR BODILY INJURY LIABILITY LIMITS OR COMBINED SINGLE LIMIT FOR LIABILITY COVERAGE UNTIL YOU MAKE ANOTHER SELECTION ON THIS FORM. IF YOU WOULD LIKE TO AMEND YOUR REJECTION OR PREVIOUS SELECTION, PLEASE INDICATE BELOW AND SUBMIT THIS FORM WITH THE DESIRED CHANGES.

I reject Uninsured Motorist Coverage entirely and understand that my policy will not include this coverage.

I select Uninsured Motorist limit(s) equal to my Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage. (If you select this option disregard the bold statement at the heading of this form unless the named insured is designated as an individual and elects the non-stacked option on page 3.)

I select the following Uninsured Motorist Coverage limit(s) listed on page 2 which are lower than my Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage. Please check with your agent or carrier for the limits offered by your company. Please indicate limits on page 2.

AGENCY: CARRIER NAIC CODE

AGENCY CUSTOMER ID:

POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S)

ACORD 61 FL (2011/10) Page 1 of 3 © 1993-2011 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:

ACORD 61 FL (2011/10) Page 2 of 3

SELECTION / REJECTION OF UNINSURED MOTORIST COVERAGE (continued)

Split Limits Combined Single Limit

$10,000 / 20,000 $20,000

$25,000 / 50,000 $50,000

$50,000 / 100,000 $100,000

$100,000 / 300,000 $250,000

$250,000 / 500,000 $300,000

$500,000 / 1,000,000 $500,000

$ $1,000,000 Other

$ Other

I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued at the same Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage. If I decide to select another option at some future time, I must let the company or my agent know in writing.

Applicant's Signature Date

SECTION B

NEW CUSTOMERS - IF YOU DO NOT ELECT ANY OF THE BELOW, YOUR POLICY WILL NOT INCLUDE UNINSURED MOTORIST COVERAGE.

RENEWAL / EXISTING CLIENTS - IF YOU HAVE PREVIOUSLY COMPLETED AND SIGNED AN ELECTION OF COVERAGE FORM AND DO NOT WISH TO CHANGE YOUR ELECTION, NO FURTHER ACTION IS REQUIRED AND SUCH ELECTION WILL BE REFLECTED ON YOUR MOST CURRENT DECLARATION PAGE(S). IF YOU WOULD LIKE TO AMEND YOUR REJECTION OR PREVIOUS SELECTION, PLEASE INDICATE BELOW AND SUBMIT THIS FORM WITH THE DESIRED CHANGES.

I select the following Uninsured Motorist Coverage limit(s). Please check with your agent or carrier for the limits offered by your company.

Combined Single Limit $

Bodily Injury Liability Limits $ each Person

$ each Accident

I reject Uninsured Motorist Coverage entirely and understand that my policy will not include this coverage.


Limits not available Limit not available

AGENCY CUSTOMER ID:

ACORD 61 FL (2011/10) Page 3 of 3

SECTION C

ELECTION OF NON-STACKED OR STACKED* UNINSURED MOTORIST COVERAGE

(Do not complete if you have rejected Uninsured Motorist Coverage)

If the named insured is designated as an individual, you have the option to purchase, at a reduced rate, the non-stacked (limited) type of Uninsured Motorist Coverage. If you are designated as other than an individual, your policy will include non-stacked Uninsured Motorist Coverage unless you reject Uninsured Motorist Coverage entirely. Under this coverage, if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this policy will apply only to the extent of coverage, if any, which applies to that vehicle in this policy. If an injury occurs while occupying someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of Uninsured Motorist Coverage available on any one vehicle for which you are a named insured, insured family member, or insured resident of the named insured's household. This policy will not apply if you select the coverage available under any other policy issued to you or the policy of any other family member who resides with you.

If you do not elect to purchase non-stacked coverage, your policy limit(s) for each motor vehicle are added together (stacked*) for all covered injuries. Thus, your policy limit(s) would automatically change during the policy term if you increase or decrease the number of autos covered under your policy.

NEW CUSTOMERS - IF YOU DO NOT ELECT ANY OF THE BELOW, YOUR POLICY WILL INCLUDE STACKED* UNINSURED MOTORIST COVERAGE.

RENEWAL / EXISTING CLIENTS - IF YOU HAVE PREVIOUSLY COMPLETED AND SIGNED AN ELECTION OF COVERAGE FORM AND DO NOT WISH TO CHANGE YOUR ELECTION, NO FURTHER ACTION IS REQUIRED AND SUCH ELECTION WILL BE REFLECTED ON YOUR MOST CURRENT DECLARATION PAGE(S). IF YOU CHANGE YOUR BODILY INJURY LIABILITY LIMITS OR COMBINED SINGLE LIMIT FOR LIABILITY COVERAGE, WE WILL STACK* YOUR UNINSURED MOTORIST COVERAGE UNTIL YOU MAKE ANOTHER ELECTION ON THIS FORM. IF YOU WOULD LIKE TO AMEND YOUR REJECTION OR PREVIOUS ELECTION, PLEASE INDICATE BELOW AND SUBMIT THIS FORM WITH THE DESIRED CHANGES.

I hereby elect the non-stacked form of Uninsured Motorist Coverage.

I hereby elect the stacked* form of Uninsured Motorist Coverage. (If you elect this option, disregard the bold statement on page 1 at the heading of the form, unless you selected Uninsured Motorist limits less than your Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage on page 1 of this form.)

I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued at the same Bodily Injury Liability Limits or Combined Single Limit for Liability Coverage. If I decide to select another option at some future time, I must let the company or my agent know in writing.


* If you are not an individual, stacking of Uninsured Motorist Coverage is not available.

AGENCY CUSTOMER ID:

FLORIDA AUTO SUPPLEMENT

AGENCY CARRIER NAIC CODE

POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S)

PERSONAL INJURY PROTECTION (NO-FAULT COVERAGE) OPTIONS

Pursuant to Florida law, every owner or registrant of a motor vehicle required to be registered and licensed in Florida, shall maintain Personal Injury Protection (PIP). This is often referred to as no-fault coverage.

Basic PIP Coverage provides for 80% of covered medical expenses and 60% of covered work loss expenses. It also covers replacement services expenses and death benefits. The total aggregate limit for all PIP benefits is $10,000 per person. Refer to your policy for the prevailing coverage provisions.

You may elect a deductible and to exclude coverage for loss of gross income and loss of earning capacity ("lost wages" or "work loss"). These elections apply to the named insured alone or to the named insured and all dependent resident relatives. A premium reduction will result from these elections. The named insured is hereby advised not to elect the lost wage exclusion if the named insured or dependent resident relatives are employed, since that would preclude the payment of lost wages in the event of an accident.

No deductible or exclusion of work loss benefits will apply, unless you make an election below. However, if this is a renewal policy, the limits and options elected for the PIP Coverage of your expiring policy will apply for the renewal policy unless you make a different election below.

Florida law allows you to select various deductible options to apply to the coverage as well as various work loss exclusions. Please see Options I and II to make your selections. Options III and IV are optional benefits. Check with your agent or carrier to determine if Options III and IV are offered by your company.

OPTION I. DEDUCTIBLE

Check the applicable box(es) below.

I do not want a deductible to apply to my policy's Personal Injury Protection Coverage.

I hereby elect the deductible indicated below. (Choose only one)

Named Insured and All Deductible Amount Named Insured Only Dependent Resident Relatives

$250

$500

$1000

OPTION II. EXCLUSION OF WORK LOSS BENEFITS

If you wish to exclude work loss benefits, check the applicable box below.

Exclude Work Loss benefits for the Named Insured and All Dependent Resident Relatives.

Exclude Work Loss benefits only for Named Insured.

Includes copyrighted material of Insurance Services Office Inc. with its permission. ACORD 62 FL (2011/10) Page 1 of 2 © 2008, 2011 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:

PERSONAL INJURY PROTECTION (NO-FAULT COVERAGE) OPTIONS (continued)

OPTION III. EXTENDED PERSONAL INJURY PROTECTION BENEFITS

NOTE: You cannot have a PIP Deductible (Option I) with Extended PIP.

OPTION A

For the Named Insured and All Dependent Resident Relatives, this coverage provides for:

• 100% of medically necessary expenses; • 80% of work loss; • Replacement services expenses; and • Death Benefits

AND For any other injured person, this coverage provides for:


OR

OPTION B

For the Named Insured and All Dependent Resident Relatives, this coverage provides for:

• 100% of medically necessary expenses; • NO work loss; • Replacement services expenses; and • Death Benefits

AND For any other injured person, this coverage provides for:


If you choose this option, you MUST select the exclusion of work loss for the Named Insured and All Dependent Resident Relatives in Option II on page 1.

If you would like to select Extended PIP for an increased premium, check the appropriate box below and make sure your previous selections are consistent with this option.

I choose OPTION A as outlined above.

I choose OPTION B as outlined above. (Make sure that you select to exclude work loss coverage for both the Named Insured and All Dependent Resident Relatives under Option II on page 1)

OPTION IV. ADDITIONAL PERSONAL INJURY PROTECTION BENEFITS

If you do not select a deductible (Option I), you may increase the $10,000 Basic PIP limit by adding one of the following additional limits for an increased premium. You MUST also select one of the Extended PIP options in Option III above if you want Additional PIP. If you want Additional PIP, check the appropriate space below and make sure that your previous selections are consistent with this option. Please check with your agent or carrier for the limits offered by your company.

$10,000 additional limit




$ additional limit

I understand that the deductible and/or benefit election(s) indicated above shall apply on the policy in effect at the time this form is executed and all future renewal policies until I notify the company in writing of any changes.

My signature below indicates that the options have been explained to me and evidences my actual knowledge and understanding of the availability of these options, as well as the options I have elected.


ACORD 62 FL (2011/10) Page 2 of 2

Option

s III a

nd IV

are

NOT CURRENTLY

AVAILA

BLE.

Please

sign

below

.

FLORIDA COMMERCIAL INSURANCE APPLICATION NON-FLEET · INSURANCE APPLICATION NON-FLEET (Commercial...

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