SUTTER INSURANCE COMPANY 1301 Redwood Way, Suite 200, Petaluma, CA COMMERCIAL VEHICLE PHYSICAL DAMAGE APPLICATION CA

Transcription

1 G SU SUC CMPY 1301 edwood Way, Suite 200, Petaluma, C CMMC VHC PHYSC DMG PPC C 1. ame of Business: ndividual Partnership Corporation 2. DB : 3. ame of Person Completing pplication: itle: 4. Mailing address: Street ddress City State Zip 5. pplicant's business: 6. Years in Business: 7. Principal Garaging ddress: Street ddress City State Zip 8. Phone umber: ( ) 9. Date coverage desired: 10. stimated financial worth: $ 11. Gross receipts/last year: $ 12. stimated next year: $ 13 Contact ame for nspection: Contact Phone umber: P D S ist all cargo carried: ame of liability carrier: What is applicant s maximum radius of operation? XP YS SPSS YS XP YS SPSS YS 1. With the exception of any encumbrances, are any vehicles not solely owned by and registered to the applicant? 8. Does applicant understand that coverage being applied for will exclude vehicles rented or leased without drivers? 2. Does applicant own any equipment not scheduled on this application? 9. re any vehicles customized, altered or have special equipment? 3. s any cargo owned by the pplicant? 10. Has insurance been cancelled or refused by any company in last 3 years? 4. Does applicant rent or lease equipment to others without drivers? 11. re D filings required? f Yes; umber? 5. Has applicant ever been in an assigned risk plan? 12. re PUC filings required? f Yes; umber? 6. re there any hold harmless agreements? 13. re DMV filings required? f Yes; umber? 7. re any vehicles used by family members not listed on the application? xplanations: H S Y D V F M P C D SS HSY F H PS H YS From o Physical Damage osses Carrier ame Policy o. Mo Yr Mo Yr umber mount # DV'S FU M Date of Birth State Driver's icense nfo icense umber o. Yrs. Commercial Driving o. Yrs. mployed By pplicant o. of ccidents ast 3 Yrs. S 3054 (5-13) SU SUC CMPY Page 1 of 2 $ $ $ o. of Minor Violations ast 3 Yrs. DD FM 1. Does applicant employ drivers under age 25? YS o f YS, are all such drivers listed above? Yes o 2. Does applicant understand that coverage being applied for will exclude coverage on vehicles being operated by drivers under age 25 that are not listed as drivers above or reported to the company by subsequent written notice? YS o 3. re driving records checked and ordered on new drivers at or prior to employment? YS o 4. Does applicant understand that if this application is accepted they will be required to report all new drivers to the company within 30 days? YS o o. of Major Violations ast 3 Yrs.

2 Unit # 1 Model Year rade ame Body ype dentification # (V#, Serial #) GVW adius imit wned or eased imit of iability Deductible 2 V H C S Special Surcharge applied? Yes o f Yes, describe: H D he automobiles described above under tem umbers corresponding to those indicated below are mortgaged as follows and loss, if any, under Comprehensive, Collision, Fire, ightning or ransportation, heft, or Combined dditional shall be payable to the named nsured and mortgagee named below, as their interest may appear. uto # ame of oss Payee ddress of oss Payee MKS: C PPC BY MY SGU CKWDG H UDSD D G WH H FWG: 1. his is my full authorization to release a claim loss history on the policies listed in this application to the Sutter nsurance Company Fax # his authorization does not authorize release of any specific records or documents in your claim files. his authorization expires upon the expiration of any coverage extended as a result of this application. his authorization is in compliance with the California nsurance Code; rticle 6.6 nsurance and Privacy Protection ct, Section and , and itle 10, California Code of egulations, Sections through ; and 2. routine inquiry may be made by Sutter to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided; and 3. his policy has a significant restriction for owing and Storage expenses. Up to $5,000 of the imit of iability indicated in the policy declarations, for a specific covered auto, may be used for owing and Storage expenses arising out of a loss to any one covered automobile. 4. he nsurance applied for will XCUD coverage on any covered auto while it is in the custody of or operated by drivers under 25 years of age, unless such person is named as a driver in this application or is added by endorsement to the policy, and vehicles rented or leased to others without drivers; and 5. o insurance shall be effective until Sutter, or its authorized representative, receives and approves this application; and 6. his program may be available with a monthly payment option from SU, and that if this option is elected there will be: a $20 Billing Fee applied to each installment and supplemental bill as long as the annual premium balance is not paid in full, a $20 ate Payment Fee applied when any payment is not postmarked or received by the due date, a $25 eturned Payment Fee applied if any payment is returned by your financial institution unpaid. 7. completed this application with the guidance of my broker as defined in Section 1623 of the California nsurance Code, who is indicated within this application and the facts stated herein are true and request the company to issue the nsurance policy and any renewals there from in reliance hereon; and 8. hereby apply for a policy of nsurance set forth above on the basis of statements contained herein, and that my Broker has reviewed and explained so that understand all Coverages, imitations and xclusions contained in the nsurance being applied for; and Signature of pplicant: Date: C BK By my signature hereby declare that all Coverages, imitations, and xclusions contained in the nsurance being applied for have been reviewed with and explained to the applicant. ame of pplicant s Broker: icense #: Street ddress: City: State: Zip Code: Signature of pplicant s Broker: Date: S 3054 (5-13) SU SUC CMPY Page 2 of 2

3 HS DSM CHGS H PCY. PS D CFUY M F US DSM (MG CVG 12 WS SS) DSM F US WH CMMC U CVG FMS n consideration of the premium at which this policy is written, it is hereby understood and agreed that coverage shall be in effect under this policy only while a covered auto listed in the policy declarations or added by endorsement indicating a radius of 12 Western States or some representation thereof, is operated within the legal boundaries of the states of: rizona, California, Colorado, daho, Montana, evada, ew Mexico, regon, exas, Utah, Washington and Wyoming. Furthermore, CVG is provided when a covered auto listed in the policy declarations or added by endorsement is operated for any reason outside of the legal boundaries of the states listed above. CVG CVG!! W C V D U M WY C D SD KS M M W M H KY WV P V Y M V H M C J D MD Z M K SC C X MS G F SCHDU Covered uto o. Year Make Model adius Vehicle dentification umber (V) nformation required to complete this Schedule, if not shown above, will be shown in the Declarations. ll other terms, conditions, and agreements of the policy shall remain unchanged. his endorsement forms a part of Policy o. issued to: by the SU SUC CMPY and is effective at 12:01.M. on FFCV D at the principle garaging location indicated in the policy declarations By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s Signature (equired) Date (equired) S3036 (1-13) SU SUC CMPY Page 1 of 1

4 SU nsurance Company PCYHD DSCSU C F SM SUC CVG Under the errorism isk nsurance ct of 2002, effective ovember 26, 2002 (the ct ), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the ct: he term certified act of terrorism means any act that is certified by the Secretary of the reasury, in concurrence with the Secretary of State, and the ttorney General of the United States to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion; and that causes losses of at least $5,000,000. You should know that coverage for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States pays 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. he premium for this coverage is shown below and does not include any charges for the portion of loss covered by the federal government under the ct. CCDC WH H C, YU MUS CHS CCP JC CVG F CFD CS F SM. SC JC F CFD SM SUC CVG XXX hereby elect to purchase certified terrorism coverage for a prospective premium of $ 30. hereby reject the purchase of certified terrorism coverage. Policyholder/pplicant s Signature Print ame Policy umber, if available Date S3420 (9-07) SU SUC CMPY Page 1 of 1

5 HS DSM CHGS H PCY. PS D CFUY. CMMC WG CVG M DSM F US WH CMMC U PHYSC DMG P his endorsement modifies insurance provided under the following: SC il M F BY he following is added: d. We will also pay up to $5000 for the combined towing, storage and labor costs resulting from the ownership, maintenance or use of a covered automobile that is involved in a covered loss to which this insurance applies. For towing, we will only pay for towing by a qualified towing service for the cost to the nearest repair facility capable of making the necessary repairs, unless we agree with you in advance to tow to another repair facility. dditionally, we will only pay for labor performed at the place of disablement and for storage required to complete the necessary repairs. he most we will pay for loss to any one covered automobile, including Commercial owing xpenses, is the applicable limit defined in a. through c. Charges associated with the recovery, storage, salvage or removal of cargo are not covered hereunder. ll other terms, conditions, and agreements of the policy shall remain unchanged. By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s Signature (equired) Date (equired) S3566 (5-13) SU SUC CMPY Page 1 of 1

6 HS DSM CHGS H PCY. PS D CFUY. CC F UPD DV his endorsement modifies insurance provided under the following: M UCK CG CVG FM UCKS CVG FM UMB PHYSC DMG SUC FM he following is added to the policy Conditions and applies in addition to the Common Policy Conditions: You must report all new drivers to us within 30 days after employment by you. Should the driver not meet our underwriting standards, we reserve the right to request that you place the driver in a non-driving capacity in your employ. You agree that a failure by you to comply with this condition of the policy will represent a material change in the hazard insured against as used in California nsurance Code 675. You further agree that we may cancel this policy in accordance with this applicable insurance code, even if the policy has been in effect for 60 days or more. ll other terms, conditions, and agreements of the policy shall remain unchanged. By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s Signature (equired) Date (equired) S3568 (5-13) SU SUC CMPY Page 1 of 1