PRODUCER'S SIGNATURETIMEDATEAPPLICANT'S SIGNATURE
APPLICANT PLEASE READ
I HEREBY DECLARE THAT ALL THE REPRESENTATIONS CONTAINED HEREIN ARE TRUE AND THAT THESE REPRESENTATIONS ARE
OFFERED AS AN INDUCEMENT TO THE COMPANY TO ISSUE THE POLICY FOR WHICH I AM APPLYING. I UNDERSTAND AND AGREE THAT THE
INSURANCE COMPANY MAY RELY ON THIS APPLICATION AND THE INFORMATION CONTAINED IN MY DRIVING RECORD AND THE DRIVING
RECORDS OF THE OTHER OPERATORS, SAID DRIVING RECORDS I NOW GRANT THE INSURANCE COMPANY PERMISSION TO OBTAIN. I
UNDERSTAND THAT THE POLICY WILL BE NULL AND VOID IF THE CHECK PRESENTED TO THE AGENT, BROKER, MGA OR COMPANY FOR
THE INITIAL POLICY IS RETURNED BY THE FINANCIAL INSTITUTION FOR ANY REASON. I FURTHER UNDERSTAND THE INSURANCE
PREMIUMS FOR THE ABOVE COVERAGE ARE SUBJECT TO CHANGES BASED ON THE SAID DRIVING RECORDS. I UNDERSTAND AND AGREE
THAT IF THE REPRESENTATIONS CONTAINED HEREIN ARE FALSE OR MISLEADING, SAID MISREPRESENTATIONS SHALL BE DEEMED
MATERIAL AND MAY RESULT IN CANCELLATION OF THIS POLICY AND DENIAL OF ALL OR PART OF THE COVERAGE PROVIDED IN THE
POLICY FOR WHICH I AMAPPLYING.
NY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES AN APPLICATION
FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
FROM TO
FROM TO
FROM TO
FROM TO
RESERVES
PD
POLICY #INSURANCE CARRIER
POLICY
PERIOD
TOTAL
MOUNT
PAID BI
TOTAL
RESERVES
BI
MOUNT
PAID PD
NUMBER
OF
CCIDENTS
NO
YES
NO
YES
NO
YES
PREVIOUS INSURANCE AND LOSS EXPERIENCE
DESCRIPTION OF VIOLATIONS
& ACCIDENTS (PAST 3 YEARS)
DRIVER
#
MVR
VERIFIED
YES/NO
NAME
DATE OF BIRTH
DRIVER LICENSE NUMBER & STATE
DRIVER INFORMATION
Inactive-Proprietors,
Partners or Officers
and their relatives
and the relatives of
any persons
described in Class I
CLASS II
NON-
EMPLOYEES
LL OTHERS
CLASS I
EMPLOYEES
REGULAR OPERATORS
CLASS OF OPERATORS
BY LOCATION NUMBER
AUTO DEALERS OPERATORS
Street, City, County, State, Zip CodeLocation #
Premises Information:
Policy Number:
ACI-GA 04/05
DEFINITIONS:
CLASS I EMPLOYEES
REGULAR OPERATOR - PROPRIETORS, PARTNERS AND OFFICERS ACTIVE
IN THE GARAGE OPERATION, SALESPERSONS, GENERAL MANAGERS,
SERVICE MANAGERS, ANY EMPLOYEE WHOSE PRINCIPAL DUTY INVOLVES
THE OPERATION OF COVERED AUTOS OR WHO IS FURNISHED A COVERED
AUTO.
ALL OTHERS - ALL OTHER EMPLOYEES
CLASS II - NON-EMPLOYEES
ANY OF THE FOLLOWING PERSONS WHO ARE REGULARLY FURNISHED
WITH A COVERED AUTO: INACTIVE-PROPRIETORS, PARTNERS OR
N
DESCRIBE
2.
NOTE: 1. PART-TIME EMPLOYEES WORKING AN AVERAGE OF 20 HOURS
OR MORE A WEEK FOR THE NUMBER OF WEEKS WORKED ARE
TO BE COUNTED AS 1 RATING UNIT EACH.
PART-TIME EMPLOYEES WORKING AN AVERAGE OF LESS THAN
A WEEK FOR THE NUMBER OF WEEKS WORKED ARE TO BE
COUNTED AS 1/2 RATING UNIT.
CLASS I.
OFFICERS AND THEIR RELATIVES AND THE RELATIVES OF ANY PERSO
D IN
