Read ACORD 127 text version

ACORD

PRODUCER

TM

BUSINESS AUTO SECTION

APPLICANT (First Named Insured) EFFECTIVE DATE EXPIRATION DATE

DATE

PHONE (A/C, No, Ext):

DIRECT BILL AGENCY BILL

PAYMENT PLAN

AUDIT

CODE: AGENCY CUSTOMER ID:

SUB CODE:

FOR COMPANY USE ONLY

COVERAGES/LIMITS

USE ACORD 137 FOR YOUR STATE TO PROVIDE COVERAGES/LIMITS INFORMATION

DRIVER INFORMATION ACORD 163 attached for additional drivers

DOC USE VEH # % USE LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS. DRIVER MAR YRS YEAR DRIVERS LICENSE NUMBER/ STATE DATE NAME (Include address, if required) SEX STAT DATE OF BIRTH # EXP LIC SOCIAL SECURITY NUMBER LIC HIRE

GENERAL INFORMATION

EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES YES NO

1. WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT? 2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS? 3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION? 4. ARE ANY VEHICLES LEASED TO OTHERS? 5. ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE SPECIAL EQUIPMENT? 6. ARE ICC, PUC OR OTHER FILINGS REQUIRED? 7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?

DESCRIPTION OF GARAGE/STORAGE LOCATIONS

8. ANY HOLD HARMLESS AGREEMENTS? 9. ANY VEHICLES USED BY FAMILY MEMBERS? IF SO, IDENTIFY IN REMARKS. 10. DOES THE APPLICANT OBTAIN MVR VERIFICATIONS? 11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD? 12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION? 13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION? 14. ANY DRIVERS WITH MOVING TRAFFIC VIOLATIONS? 15. HAS AGENT INSPECTED VEHICLES?

MAXIMUM DOLLAR VALUE SUBJECT TO LOSS

ADDITIONAL INTEREST/CERTIFICATE RECIPIENT

INTEREST RANK: NAME AND ADDRESS REFERENCE #: ADDITIONAL INSURED LOSS PAYEE MORTGAGEE LIENHOLDER EMPLOYEE AS LESSOR ITEM DESCRIPTION:

ACORD 45 attached for additional names

CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER LOCATION: VEHICLE: BUILDING: BOAT:

SCHEDULED ITEM NUMBER: OTHER

REMARKS

ACORD 127 (2000/04)

PLEASE COMPLETE REVERSE SIDE

© ACORD CORPORATION 1993

VEHICLE DESCRIPTION

VEH # YEAR MAKE: MODEL: CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

ACORD 129 attached for additional vehicles

BODY TYPE: V.I.N.: LIC STATE TERR GVW/GCW CLASS PP SIC VEHICLE TYPE SPEC FACTOR COML SEAT CP RADIUS SYM/AGE COST NEW

$

FARTHEST TERM

USE

COMM'L PLEASURE FARM RETAIL SERVICE

CHECK COVERAGES

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR BODY TYPE:

V.I.N.: TERR

< 15 MILES 15 MILES +

VEH # YEAR

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

MAKE: MODEL: LIC STATE USE CHECK COVERAGES

VEHICLE TYPE PP GVW/GCW CLASS SIC SPEC FACTOR COML

SYM/AGE

COST NEW

$

RADIUS FARTHEST TERM

CITY, STATE, ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL

SEAT CP

COMM'L PLEASURE FARM RETAIL SERVICE

ADD'L NOFAULT MED PAY UNINS MOTOR

< 15 MILES 15 MILES +

LIAB NOFAULT

UNDRINS MOTOR TOWING & LABOR SPEC C OF L

F FT FTW

LSP COMP COLL

DEDUCTIBLES

ACV ST AMT $ $

COMP

AA $

SPEC MISC C OF L DR/CR: TOTAL PREM COLL $

ACORD 127 (2000/04)

Information

ACORD 127

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