|
NorthAmerican |
Print/Complete form then Fax to: 562-595-4362 |
Account Executive Ralph Riley Date Time ______
NEED BY
NEED BY PHONE #:
Date: Time: Contact: Fax #:
Primary
Auto Motor Truck
Cargo General
Liability (ACORD
App.)
$750/$1,000,000
$50/$100/$200/other $500/$1,000,000
1. Applicant:
FEIN/SS:
Corporation Individual Partner Other:
2. Mailing address:
3. Garaging address:
4. Permanently
leased or contracted to:
Address: Phone:
5. Filings Required: DMV: CA #
Authority to Haul Hazardous
Materials? Yes No
6. Is
this a New Venture? Yes No If
No, how many years in business under
the above name:
7. Insurance
History (3yrs, attach currently valued loss runs)
|
LIABILTY |
Name
of Carrier |
Policy
Number |
Claims
Paid |
Premium |
Expiration
Date |
|
Current
Year |
|
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|
1st
Prior Year |
|
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2nd
Prior Year |
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|
Physical Dam |
Name
of Carrier |
Policy
Number |
Claims
Paid |
Premium |
Expiration
Date |
|
Current
Year |
|
|
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|
1st
Prior Year |
|
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2nd
Prior Year |
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|
MTC |
Name
of Carrier |
Policy
Number |
Claims
Paid |
Premium |
Expiration
Date |
|
Current
Year |
|
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|
|
|
|
1st
Prior Year |
|
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2nd
Prior Year |
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GL |
Name
of Carrier |
Policy
Number |
Claims
Paid |
Premium |
Expiration
Date |
|
Current
Year |
|
|
|
|
|
|
1st
Prior Year |
|
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2nd
Prior Year |
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Claim Details:
8. If
New Venture, need employer history. (5 yrs)
Employer: Hire Date: Termination Date:
Address:
Phone:
Employer: Hire Date: Termination Date:
Address:
Phone:
Employer: Hire Date: Termination Date:
Address:
Phone:
9. Commodities Hauled and % of each: % %
% % %
% % %
10 Cargo:
Per
Vehicle Limit: Deductible:
Average Load: Maximum Load:
11. Radius Largest
cities (pick up/drop off):
12. Drivers: Name
DOB SS# Yrs. Exp. Driver’s License #
1.
2.
13. Vehicles to be covered
(Vehicles Inspection required on vehicles 15yrs or older)
Year Make Body Type VIN# GVW/Gals Stated Amount
1.
2.
14. Trailer
Interchange: $