Truckers Occupational Accident Insurance Questionnaire Form Page 4
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47. Please complete the following chart. (Attach a separate sheet, if necessary.)
Workers’ Compensation Manual Rate
Owner-Operator Name
State of Domicile
for State of Domicile
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
I hereby acknowledge that all answers and statements contained, including the attached data, are true and complete. I understand
that the Contingent Liability contract is registered and delivered as a surplus lines coverage under applicable state law. I also
understand that no coverage will become effective until an application has been signed and approved by the Insurance Company,
a policy of Insurance is issued, and the required premium is paid.
Broker/Agent Signature
Applicant Signature
Date: _________________________________________________
Date: ________________________________________________
Please tell us about your organization.
Producer Name: __________________________________ Producer Code: ___________________________________
(if known)
Contact Person: __________________________________________________________________________________
Street Address: __________________________________________________________________________________________
City: ___________________________________________ State: ____________ Zip Code: ___________________
Telephone Number: ______________________________ Fax Number: ____________________________________
(
)
(
)
E-Mail Address: _________________________________ Web Address: ___________________________________
Requested Commission: ___________________________
Is Agent/Broker Surplus Lines Licensed in state of policy issuance?
Yes
No If No, please name Agent/Broker
authorized to assume duties and responsibilities of Registered Surplus Lines Agent/Broker, below.
TO BE COMPLETED BY SURPLUS LINES AGENT/BROKER
Broker/Agency: ____________________________________________________________________________________________________
Contact Person: __________________________________________________________________________________________
Street Address: _________________________________________________________________________________________
City: __________________________________________________ State: ______________________ Zip: _________________
(
)
Telephone Number: ______________________________________________________________________________________
(
)
Fax Number: __________________________________________________________________________________________
The underwriting Member Companies of American International Group, Inc. for these products are:
American International South Insurance Company
National Union Fire Insurance Company of Pittsburgh, PA
American Home Assurance Company
Insurance Company of the State of Pennsylvania
National Union Fire Insurance Company of Louisiana
Illinois National Insurance Company
AIU Insurance Company
and Lexington Insurance Company.
HCMB:OCC:1Q 01/00
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