ACORD ™

BUSINESS AUTO

DATE

PRODUCER
PHONE: (A/C, No, EXT)
CODE:
SUBCODE:
AGENCY CUSTOMER ID:

APPLICANT (First Named Insured)

EFFECTIVE DATE	EXPIRATION DATE		DIRECT BILL	PAYMENT PLAN	AUDIT
			AGENCY BILL

COVERAGES/LIMITS

COVERAGES

COVERED AUTO SYMBOLS

LIMITS

COVERAGES

COVERED AUTO SYMBOLS

LIMITS

LIABILITY

1 4 9
2 7 6
3 8

CSL
BI EA PER

BI EACH ACCIDENT

PROPERTY DAMAGE

PERSONAL INJURY PROTECTION

5
7

OR EQUIVALENT
NO-FAULT COVERAGE

DEDUCTIBLE

PHYSICAL DAMAGE

ADDITIONAL P.I.P.

> 5
> 7

TOTAL W/C

TOWING & LABOR	/> 3 7	$
COMPREHENSIVE	2 4 8 3 7	$
SPECIFIED CAUSES OF LOSS	2 4 8 3 7	$
COLLISION	2 4 8 3 7	$

$ M/E

MEDICAL PAYMENTS

2 4 8
3 7

EACH PERSON

UNINSURED MOTORIST

2 6
3 7
4

CSL
BI EA PER

BI EACH ACCIDENT

PROPERTY DAMAGE

UNDERINSURED MOTORIST

2 6
3 7
4

CSL
BI EA PER

HIRED PHYSICAL DAMAGE

BI EACH ACCIDENT

	COVERAGE/DEDUCTIBLE
STATES	COMP	$
# DAYS	SPEC C OF L	$
# VEH	COLL	$
COVERAGE IS: PRIMARY SECONDARY

PROPERTY DAMAGE

HIRED/BORROWED LIABILITY

STATES

COST OF HIRE

IF ANY BASIS

NON-OWNED LIABILITY

STATES

GROUP TYPE

NUMBER OF

EMPLOYEES

VOLUNTEERS

PARTNERS

ENDORSEMENTS, FORMS, CONDITIONS

DRIVER INFORMATION

LIST ALL DRIVERS, INCLUDING FAMILY MEMEBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS.

DRIVER #	NAME (Include address, if required)	DOB	YR LIC	DRIVERS LICENSE NUMBER/SSN	STATE LIC	USE #	% USE

VEHICLE DESCRIPTION

VEH #	YEAR	MAKE:		BODY TYPE:		SYM/AGE	COST NEW
		MODEL:		V.I.N.:			$

CITY, STATE, ZIP WHERE GARAGED	TERR	GVW/GCW	CLASS	SIC	FACTOR	SEAT CP	RADIUS	FARTHEST TERM

DRIVE TO WORK/SCHOOL	USE		CHECK COVERAGES		DEDUCTIBLES
UNDER 15 MILES 15 MILES OR OVER	PLEASURE FARM COMM'L	RETAIL SERVICE	LIAB PIP ADD'L PIP MED PAY UNINS MOTOR UNDRINS MOTOR TOWING & LABOR	SPEC C OF L F FT FTW LSP COMP COLL	ACV AA ST AMT $ COMP SPEC C OF L $ $ COLL

VEH #	YEAR	MAKE:		BODY TYPE:		SYM/AGE	COST NEW
		MODEL:		V.I.N.:			$

CITY, STATE, ZIP WHERE GARAGED	TERR	GVW/GCW	CLASS	SIC	FACTOR	SEAT CP	RADIUS	FARTHEST TERM

DRIVE TO WORK/SCHOOL	USE		CHECK COVERAGES		DEDUCTIBLES
UNDER 15 MILES 15 MILES OR OVER	PLEASURE FARM COMM'L	RETAIL SERVICE	LIAB PIP ADD'L PIP MED PAY UNINS MOTOR UNDRINS MOTOR TOWING & LABOR	SPEC C OF L F FT FTW LSP COMP COLL	ACV AA ST AMT $ COMP SPEC C OF L $ $ COLL

VEH #	YEAR	MAKE:		BODY TYPE:		SYM/AGE	COST NEW
		MODEL:		V.I.N.:			$

CITY, STATE, ZIP WHERE GARAGED	TERR	GVW/GCW	CLASS	SIC	FACTOR	SEAT CP	RADIUS	FARTHEST TERM

DRIVE TO WORK/SCHOOL	USE		CHECK COVERAGES		DEDUCTIBLES
UNDER 15 MILES 15 MILES OR OVER	PLEASURE FARM COMM'L	RETAIL SERVICE	LIAB PIP ADD'L PIP MED PAY UNINS MOTOR UNDRINS MOTOR TOWING & LABOR	SPEC C OF L F FT FTW LSP COMP COLL	ACV AA ST AMT $ COMP SPEC C OF L $ $ COLL

VEH #	YEAR	MAKE:		BODY TYPE:		SYM/AGE	COST NEW
		MODEL:		V.I.N.:			$

CITY, STATE, ZIP WHERE GARAGED	TERR	GVW/GCW	CLASS	SIC	FACTOR	SEAT CP	RADIUS	FARTHEST TERM
/>

DRIVE TO WORK/SCHOOL	USE		CHECK COVERAGES		DEDUCTIBLES
UNDER 15 MILES 15 MILES OR OVER	PLEASURE FARM COMM'L	RETAIL SERVICE	LIAB PIP ADD'L PIP MED PAY UNINS MOTOR UNDRINS MOTOR TOWING & LABOR	SPEC C OF L F FT FTW LSP COMP COLL	ACV AA ST AMT $ COMP SPEC C OF L $ $ COLL

VEH #	YEAR	MAKE:		BODY TYPE:		SYM/AGE	COST NEW
		MODEL:		V.I.N.:			$

CITY, STATE, ZIP WHERE GARAGED	TERR	GVW/GCW	CLASS	SIC	FACTOR	SEAT CP	RADIUS	FARTHEST TERM

DRIVE TO WORK/SCHOOL	USE		CHECK COVERAGES		DEDUCTIBLES
UNDER 15 MILES 15 MILES OR OVER	PLEASURE FARM COMM'L	RETAIL SERVICE	LIAB PIP ADD'L PIP MED PAY UNINS MOTOR UNDRINS MOTOR TOWING & LABOR	SPEC C OF L F FT FTW LSP COMP COLL	ACV AA ST AMT $ COMP SPEC C OF L $ $ COLL

ADDITIONAL INTEREST/CERTIFICATE RECIPIENT

INTEREST	RANK:	NAME AND ADDRESS	REFERENCE #:	CERTIFICATE REQUIRED	INTEREST IN ITEM NUMBER
ADDITIONAL INSURED					LOCATION:	BUILDING:
LOSS PAYEE					VEHICLE:	BOAT:
MORTGAGEE					SCHEDULED ITEM NUMBER:
LIENHOLDER					OTHER
EMPLOYEE AS LESSOR
		ITEM DESCRIPTION:

GENERAL INFORMATION

EXPLAIN ALL YES RESPONSES

Yes/No

WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?

ANY HOLD HARMLESS AGREEMENTS?

DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THEIR BUSINESS?

ARE EMPLOYEE HEALTH PLANS PROVIDED?

IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?

10.

IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?

ARE ANY VEHICLES LEASED TO OTHERS?

11.

DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE SPECIAL EQUIPMENT?

12.

DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?

ARE ICC, PUC OR OTHER FILINGS REQUIRED?

13.

ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS?

DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS
MATERIAL?

14.

ANY DRIVERS WITH MOVING TRAFFIC VIOLATIONS?

DESCRIPTION OF GARAGE/STORAGE LOCATIONS

MAXIMUM DOLLAR VALUE SUBJECT TO LOSS

REMARKS

UNINSURED AND UNDERINSURED MOTORISTS COVERAGES (Check the appropriate box(es) below and sign where applicable)

DO NOT USE IN AR, AZ, CA, CT, DE, FL, GA, IA, IL, MD, NJ, NV, OK, OR, PA, RI, SC, WV, USE SPECIFIC STATE SUPPLEMENT. MINIMUM UM LIMITS REQUIRED IN DC, ME, MN, MO, VT, VA, WA, WI.

I UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS (UM) AND UNDERINSURED MOTORISTS (UIM) COVERAGES HAVE BEEN EXPLAINED TO ME. I HAVE BEEN OFFERED THE OPTIONS OF:

SELECTING UM AND UIM LIMITS EQUAL TO MY LIABILITY LIMITS
SELECTING UM AND UIM LIMITS LOWER THAN MY LIABILITY LIMITS, OR
REJECTING COVERAGE ENTIRELY.

I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.	1. I SELECT UM AND UIM LIMITS INDIC IN THIS APP	(APPLICANT'S SIGNATURE)
	2. I REJECT UM BODILY INJURY COVERAGE	(APPLICANT'S SIGNATURE)
	3. I REJECT UIM BODILY INJURY COVERAGE	(APPLICANT'S SIGNATURE)
	4. I REJECT UM PROPERTY DAMAGE COVERAGE	(APPLICANT'S SIGNATURE)
	5. I REJECT UIM PROPERTY DAMAGE COVERAGE	(APPLICANT'S SIGNATURE)

ACORD 127 (2002/95)