National Indemnity - ID Truck Application
National Indemnity - ID Truck Application
National Indemnity - ID Truck Application
DESCRIPTION OF OPERATIONS
6. Describe business
Years experience New Venture? Yes No If you are a tow truck operation, do you do repossessions? Yes No
7. Is this your primary business? Yes No If no, explain
Seasonal? Yes No
8. Have you ever filed for bankruptcy? Yes No If yes, when Explain
9. Gross receipts last year Estimate for coming year Business for sale? Yes No
10. Do you operate in more than one state? Yes No If yes, list states
11. Do you haul for hire? Yes No Show largest cities entered
12. Yes No
Do you operate over a regular route? If yes, show towns operated between
13. Are you a common carrier? Yes No Are you a contract hauler? Yes No If yes, for whom
14. List all types of cargo hauled
15. Do you haul any hazardous or extra hazardous substances or materials as defined by EPA? Yes No If yes, provide complete listing
identifying all material(s) and/or chemical content
16. Do you haul your own cargo exclusively? Yes No If not, who owns it?
17. Do you pull double trailers? Yes No Triple trailers? Yes No
18. Do you rent or lease your vehicles to others? Yes No If yes, attach copy of rental or lease agreement form used.
19. Do you hire any vehicles? Yes No Complete Hired and Non-Owned Supplemental Questionnaire if coverage is desired.
SCHEDULE OF AUTOS/VEHICLES C Describe all vehicles for which application is made for insurance.
(A) Anti-
Body Type Gross Total Radius Annual
Principal Garaging Lock
Veh. Model Vehicle Make (truck, Full Vehicle Identification Vehicle # of of Mileage
Location Brakes,
No. Year & Model tractor, Number Weight Rear Opera- Per
(city & state) (B) Air
trailer, etc.) (GVW) Axles tion Vehicle
Bags
1
2
3
4
5
6
7
8
9
10
26. Will lessor be added as additional insured? Yes No If yes, give name and address of lessor for each vehicle
27. Number of Vehicles Owned: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
28. Number of Vehicles Leased: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
PHYSICAL DAMAGE COVERAGE C Complete spaces below in detail for each respective auto/vehicle described above.
Current Stated Value Value of Permanently Total Stated Physical Damage Deductible Cargo
Veh. Date Cost When
No. Purchased Purchased (excluding permanently Attached Special Amount to be Comprehensive Limit of
attached equipment) Equipment Insured Collision Insurance
Spec. C of Loss
1
2
3
4
5
6
7
8
9
10
29. Any loss payees? Yes No If yes, give name and address of mortgagee/loss payee for each vehicle
Describe Cargo Hauled % of Hauling Maximum Value Average Value Limit of Insurance Deductible
SEE PHYSICAL $500
DAMAGE $1,000
COVERAGE $2,500
SECTION Other
If applicant hauls double wide mobile homes, limit of insurance must be equal to the value of both sides combined to satisfy co-insurance.
Amount of insurance on each truck should equal maximum load carried.
52. Do you have agreements with other carriers for the interchange of equipment or transportation of loads? Yes No
If yes, attach a copy of current agreements and complete the following:
(a) With whom has such agreement(s) been made?
(b) Do the parties named in (a) carry automobile liability insurance? Yes No
If yes, name of insurance company and limits of liability (bodily injury & property damage)
(c) Under whose permit does each of the parties to the agreement(s) operate?
(d) Is there a Hold Harmless in the agreement(s)? Yes No
53. Do you barter, hire or lease any vehicles? Yes No If yes, explain
M-5551 ID (12/2010) Truck Application Page 3 of 4
MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the
policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is
acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may
not accept any funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false,
the Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be
attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that
endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the
Applicant or any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business
background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional
information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).