Commercial Auto Application
Date: 
Company Use: Received Date Policy Number Underwriter
 
 

Agent's name & address:

InsuranceGuys Insurance Services

PO Box 90359

Santa Barbara, CA 93190
Telephone:  800-585-8887 Code: 
This application will not be given consideration unless:
1)  It is fully completed and every question answered.
2)  Accompanied by a current MVR for ALL drivers.
3)  Application is signed personnally by the applicant and agent.
Applicant's Full Name:
DBA (if any):
Mailing Address - if PO Box then give actual address below:
City: State: Zip:
Phone Number: Contact Person:
Place of principal garaging. If same as above, write SAME:
Policy Requested:  Liability & Physical Damage
   Physical Damage Only
 New Policy   Renews policy #: 
Applicant is:  Individual    Partnership    Corporation    Other:
Years in business: 
Describe applicant's business operations:
Proposed
Effective Date:

at 12:01 A.M. Std. Time		 Proposed
Expiration Date:
 NOTE: Coverage cannot be bound until approved by the Company. When approved, the application and payment must be postmarked within 48 hours of the effective date: otherwise coverage will be effective at 12:01 A.M. on the date following the postmark on the envelope.
General Information - All questions must be fully answered.
1.  Must the applicant comply with the Motor Carrier Act of 1960 (MSO-90)?  Yes   No - If Yes, risk is unacceptable. 6.  Are all vehicles owned or operated shown on the application?  Yes  No - Where insured?
2.  Does the risk EVER haul hazardous substances, flammables, explosives, chemicals or acids?
 Yes  No - If Yes, risk is unacceptable.		 7.  Is applicant the registered owner of all units listed, except "unidentified trailers?"  Yes  No - If no, which units?
3.  Does the applicant operate on a regular route?
 Yes  No - If Yes, list cities/destinations: 		8.  Any policy or coverage declined, cancelled, or non-renewed?  Yes  No - If yes, explain:
4.  Does the applicant rent or lease vehicles to others?
 Yes  No - If Yes, unacceptable risk.		 9.  Is there a vehicle maintenance program in place?  Yes  No - explain:
5.  Is the applicant under contract or lease to haul for a single firm?  Yes  No - If Yes, to whom?
 10.  Does applicant ever operate outside of California?  Yes  No - If Yes, unacceptable risk.
Type of Cargo, if any, hauled and percentages. Be specific.
FILINGS:
California PUC Filing - CAL-T#    SR-22 - See Driver information   Other:
NOTE: There is a fully earned filing fee of $25 for each filing, INCLUDING REINSTATEMENTS. We must insure ALL vehicles owned or operated by the applicant to make a regulatory filing. We will not make the PUC filing on premium financed policies or on policies written for less than one year. Additional rules may apply.
Insurance History - List all claims and insurance companies for the past 3 years.
Date of Loss Type of Loss Description of Loss Amount Paid Reserve
Policy Period
From/To		 Insurance Company Policy Number Coverage
Liab a/o Phys Damage		 Did Agency handle account?
Yes/No
Coverage and Limits of Liability
1.  Bodily Injury / Property Damage Liability  15/30/10    25/50/10    50/100/25    100/300/50    100/300/50
 250/500/100   Same limits on all units.
2.  Combined Single Limit Liability  100 CSL    300 CSL    500 CSL   Same limits on all units.
3.  Medical Payments  1000    2000    5000   Same limits on all units.
4.  Uninsured Motorist - Bodily Injury  15/30    25/50    30/60   Same limits on all units - can be rejected.
5.  Uninsured Motorist - Property Damage  3500 only on units without collision - can be rejected.
6.  Specified Perils Coverage is on a per unit basis - refer to vehicle section.
7.  Collision Coverage is on a per unit basis - refer to vehicle section.
8.  Cargo
Vehicle Information - Complete for each vehicle to be insured - use additional applications if necessary.
UNIT 1 How is the unit used?  # job sites per day: 
Year/Manufacurer and Model/Body/Type Complete Serial Number Stated Value Zone
GVW or Gallons BodyType Symbol # Use Class Max. Radius Antilock Brakes Garaging Zip Code Rating Territory Spec. Perils Deductible Collision Deductible Pers. Use 4WD
 H/S  C
 S  P		  Y
 N		  Y
 N		  Y
 N
Garaging Address if different than on Page 1.
Loss Payee Complete Name and address:
Additional Insured Name and address:
ADDITIONAL EQUIPMENT: List all attached equipment to be covered for physical damage (pick-up covers, custom paint, etc) and include value in Stated Value.
1. 
2. 
3. 
 
CARGO: Maximum value $50,000. May only be written with liability and/or Physical Damage Coverage.
Commodity: 
Value:  Deductible: 
Include:   Theft  Earned Freight  Refrigerator xBreakdown
COVERAGE
PREMIUMS		 Liability
 Med. Pay
 UM - BI
 UM - PD
 Specified Perils
 Collision
 Cargo
 Total Annual
 
UNIT 2 How is the unit used?  # job sites per day: 
Year/Manufacurer and Model/Body/Type Complete Serial Number Stated Value Zone
GVW or Gallons BodyType Symbol # Use Class Max. Radius Antilock Brakes Garaging Zip Code Rating Territory Spec. Perils Deductible Collision Deductible Pers. Use 4WD
 H/S  C
 S  P		  Y
 N		  Y
 N		  Y
 N
Garaging Address if different than on Page 1.
Loss Payee Complete Name and address:
Additional Insured Name and address:
ADDITIONAL EQUIPMENT: List all attached equipment to be covered for physical damage (pick-up covers, custom paint, etc) and include value in Stated Value.
1. 
2. 
3. 
 
CARGO: Maximum value $50,000. May only be written with liability and/or Physical Damage Coverage.
Commodity: 
Value:  Deductible: 
Include:   Theft  Earned Freight  Refrigerator xBreakdown
COVERAGE
PREMIUMS		 Liability
 Med. Pay
 UM - BI
 UM - PD
 Specified Perils
 Collision
 Cargo
 Total Annual
 
UNIT 3 How is the unit used?  # job sites per day: 
Year/Manufacurer and Model/Body/Type Complete Serial Number Stated Value Zone
GVW or Gallons BodyType Symbol # Use Class Max. Radius Antilock Brakes Garaging Zip Code Rating Territory Spec. Perils Deductible Collision Deductible Pers. Use 4WD
 H/S  C
 S  P		  Y
 N		  Y
 N		  Y
 N
Garaging Address if different than on Page 1.
Loss Payee Complete Name and address:
Additional Insured Name and address:
ADDITIONAL EQUIPMENT: List all attached equipment to be covered for physical damage (pick-up covers, custom paint, etc) and include value in Stated Value.
1. 
2. 
3. 
 
CARGO: Maximum value $50,000. May only be written with liability and/or Physical Damage Coverage.
Commodity: 
Value:  Deductible: 
Include:   Theft  Earned Freight  Refrigerator xBreakdown
COVERAGE
PREMIUMS		 Liability
 Med. Pay
 UM - BI
 UM - PD
 Specified Perils
 Collision
 Cargo
 Total Annual
 
UNIT 4 How is the unit used?  # job sites per day: 
Year/Manufacurer and Model/Body/Type Complete Serial Number Stated Value Zone
GVW or Gallons BodyType Symbol # Use Class Max. Radius Antilock Brakes Garaging Zip Code Rating Territory Spec. Perils Deductible Collision Deductible Pers. Use 4WD
 H/S  C
 S  P		  Y
 N		  Y
 N		  Y
 N
Garaging Address if different than on Page 1.
Loss Payee Complete Name and address:
Additional Insured Name and address:
ADDITIONAL EQUIPMENT: List all attached equipment to be covered for physical damage (pick-up covers, custom paint, etc) and include value in Stated Value.
1. 
2. 
3. 
 
CARGO: Maximum value $50,000. May only be written with liability and/or Physical Damage Coverage.
Commodity: 
Value:  Deductible: 
Include:   Theft  Earned Freight  Refrigerator xBreakdown
COVERAGE
PREMIUMS		 Liability
 Med. Pay
 UM - BI
 UM - PD
 Specified Perils
 Collision
 Cargo
 Total Annual
 
Driver Information - List all Full-time, Part-time or occasional drivers. ALL DRIVERS MUST BE LISTED
Does applicant review MVR's prior to hiring?  Yes   No
Does applicant require current DOT Physical on all drivers?  Yes   No
Driver  Full Name as on Driver's License Date of Birth Marital
Status		 Yrs. Exp. Driver's Lic. Number State
1. 
2. 
3. 
4. 
5. 
Driver  Date List ALL Violations, convictions, and accidents for the past three years. Provide proof for not-at-fault accidents. Accidents or losses
1. 
2. 
3. 
4. 
5. 
Premium Summary
Total Premium for all vehicles: 
 
 
Hired & Non-owned Premium: 
(if applicable) 
 
 
 
Filing Fees: 
 
 
Fully Earned Policy Fee: 
 		  $50.00
TOTAL PREMIUM DUE: 
 
 
Amount remitted with application: 
Check if premium financed. 
 
  
Payment Options - If available
NOTE: Payment options only available if Topa's General Agent offers such a program. Topa Insurance Company does not directly offer this service, handle any payment options, or collect any service fees
1.  Paid-in-Full Annual or 6-month term. When paid-in-Full (no premium finance business) the policy premium is subject to a discount.
2.  Direct Bill (Annual) No Filings. Submit 25% down (plus fees) with app. Down pay + 8 Installments, each subject to a $5 service charge.
3.  Direct Bill (Annual) With PUC Filing. Certified check or money order only. Submit 25% down (plus fees) with app. Down pay + 8 Installments, each subject to a $5 service charge.
4.  Direct Bill (6 Month) No Filings. Submit 30% down (plus fees) with app. Down pay + 3 Installments, each subject to a $5 service charge.
How long has agency controlled this acount? years. Does account qualify for Commercial Account Persistency Discount? Yes No. Applicant must have been with the same agency during the previous annual policy term and claim-free. Submit copy of previous declarations and proof of claim-free. Discount, if granted, only applies to Liability. Discount is 10%.
Paid-in-Full Discount - 5%. Applies to liability coverages when applicant pays the total policy premium in full at policy inception. No Premium finance. Discount will be removed if check fails to clear the bank.
Anti-Lock Braking System (ABS) Discount - 5%. Applies to liability coverages if power unit has factory installed anti-locking device.
Applicant Questionaire - To be completed and initialed in the Applicant's Handwriting.
Have all driver's who may operate an insured vehicle on an occasional, part-time or full-time basis been listed in the driver section? This includes family members who may operate a listed vehicle.  Yes   No - explain below.

Initials:
Are all owned or operated (including vehicles under a 30 day or longer lease) commecial vehicles listed in the vehicle section?  Yes   No - explain below.

Initials:
Are all vehicles listed on the application which are operated under the insured's California PUC or any other operating authority?  Yes   No - explain below.

Initials:
Explanations:
Driver Exclusion
It is hereby understood and agreed that all coverage and OUR obligation to defend under this policy shall not apply nor accrue to the benefit of any INSURED or any third party claimant while any AUTO or MOBILE EQUIPMENT is being used or operated by any person designated below. YOU agree to reimburse US for any payment made by US to a loss payee because of lass arising from the use or operation of the AUTO or MOBILE EQUIPMENT by a person listed below.

This driver exclusion shall be binding upon every insured to whom such policy or endorsement provisions apply while such policy is in force and shall continue to be binding with respect to any continuation, renewal or replacement of such policy by the Named Insured or with respect to reinstatement of such policy within 30 days of any lapse thereof.
 
Name of person excluded: Birthdate: Relationship:

The undersigned, a named insured in the policy, and the company providing the insurance agree to the deletion of all coverage and obligation to defend while any AUTO or MOBILE EQUIPMENT is being used or operated by any person designated above.
 
 
Accepted by: _______________________________________________ Date: _______________________
TCEL-5 (12/93) 
Agreement waiving Uninsured/Underinsured Motorist Coverage
The California Insurance Codes require an insurer to provide uninsured motorist bodily injury and physical damage coverage in each bodily injury liability insurance policy It issues covering liability arising out of ownership or use of a motor vehicle. Such sections also permit the insurer and the applicant to delete such coverage completely or, with respect to uninsured motorist bodily injury coverage, to delete such coverage when a motor vehicle is operated by a natural person or persons designated by name, or agree to provide such coverage in an amount less than that required by Subdivision (m) of Section 11580.2 of the insurance Code, but not less than the financial law, which such person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to him from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same household. Uninsured motorist physical damage coverage provides coverage for property damage, within the uninsured motorist physical damage limits established by law, caused by the owner or operator of an uninsured motor vehicle. An uninsured motor vehicle includes any underinsured motor vehicle as defined in Subdivision (p) of Section 11580.2 of the insurance Code. I understand that the maximum limit of Uninsured Motorist Bodily Injury Coverage required to be offered as $30,000/$60,000.

I hereby reject Uninsured Motorist Bodily Injury Coverage entirely. This rejection shall be binding upon every insured to whom the policy applies while the policy is in force and shall continue to be so binding with respect to any continuation or renewal of the policy, or with respect to any policy issued to the named insured by the same insurer or with respect to reinstatement of the policy within 30 days of any lapse thereof.
 
 
Signature of Insured/Applicant: ___________________________________________ Date: ______________
Applicant and Agent Signatures - This must be signed or Application will be rejected.
I hereby declare and warrant that to the best of my knowledge the statements made on the application are true and complete and that these statements are made as an inducement to the Company to issue the insurance policy for which I am applying. I agree that such a policy shall be null and void if my premium payment check does not clear the bank when initially presented. I acknowledge that a $10.00 charge will apply for all returned checks due to insufficient funds.

I understand a routine investigation may be made as to my insurability, including requesting a copy of my motor vehicle record from the Department of Motor Vehicles, character, general reputation, personal characteristics, credit history, condition of vehicles and thier use. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

I further declare that I have not had an accident or loss in the last 72 hours and that I am the legal and/or registered owner of all vehicles.
 
 
Applicant's Signature: _________________________________________ Time: _________ Date: _________
I warrant and certify that all information contained herein is correct to the best of knowledge, that this form was completed and then signed by the Insured/Applicant, that a completed copy hereof has been given to the insured/applicant, and that I am retaining a duplicate copy hereof.
 
 
Agent's Signature: ___________________________________________ Time: _________ Date: _________
LOCKED TRUCK WARRANTY - CARGO COVERAGE ONLY. If cargo coverage is purchased on certain commodities with THEFT and/or EARNED FRIEGHT coverage the coverage does not apply if the vehicle is not locked and there is no sign of direct violence or forceful entry.

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