Form 62695 - Vehicle Insurance Application Form - Small Fleet Insurance Application
ADVERTISEMENT
1
2DESIRED POLICY EFFECTIVE
TIME:
am
AIG
Truck Insurance Group
DATE :
Phone (678) 320-1100
FAX (678) 320-1298
pm
600 Northpark Town Center, Suite 600
________/________/_______
______:______
1200 Abernathy Rd., N.E. , Atlanta, GA 30328
AIG
Truck Insurance Group
SMALL FLEET INSURANCE APPLICATION
GENERAL INFORMATION
Applicant Name:
City
State
County
Zip
Applicant Address
City
State
County
Zip
Principal Garaging Address(If Different)
Type Of Entity:
Applicant Phone
(
)
-
Proprietorship,
Partnership,
M.C. Number
Corporation,
Individual,
Other
Social Security Or Tax I.D. Number:
Name of Person to Contact:
Number Of Years In Business?:_____
COVERAGE DESIRED
Coverage
Limit
Deductible
Symbol
Primary Liability
300
500
750
1000
None
1000
2500
Non Trucking Use
300
500
750
1000
N/A
Personal Injury
Reject
____________
N/A
Uninsured Motorists
Reject
____________
N/A
Physical Damage
Stated Amount
$1000
$2500
MILEAGE BY STATE (Or Attach Copy of Schedule B -- Fuel Tax Summary)
State
Annual Mileage
State
Annual Mileage
State
Annual Mileage
DRIVER INFORMATION
Driver Name
Date Of Birth
License # and (State)
Date Employed
Commercial Experience
1.
/
/
(
)
/
/
2.
/
/
(
)
/
/
3.
/
/
(
)
/
/
4.
/
/
(
)
/
/
5.
/
/
(
)
/
/
6.
/
/
(
)
/
/
VIOLATIONS and ACCIDENTS
Driver Name
Date Of Violation
Details Of All Violations Or Accidents
Place
In The Last 36 Months
/
/
/
/
/
/
/
/
/
/
/
/
FINANCIAL INFORMATION
Attach a copy of the insured's most recent year end profit and loss sheet, tax statement or other financial information and any
necessary explanation.
FILINGS
Does the applicant require:
ICC Filing (provide docket #MC)
PUC Filing
Other state filings (Specify state)_____
Note: 1. We must insure all vehicles owned or operated by the insured to make an ICC or PUC filing. 2.: No filings will be make until downpayment is
received and the risk is acceptad. 3. There is a fully earned filing fee of $10.00 for filings made as a result of reinstatement.
62695 (5/95)
62695(5/95)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mvd-11268 - Affidavit Of Non-use Of Vehicle Or Affidavit Of Out-of-state Vehicle Insurance - State Of New Mexico - Motor Vehicle Division
Legal
Form Gew-ta-rv-5 - General Excise/use, Employer's Withholding, Transient Accommodations And Rental Motor Vehicle, Tour Vehicle & Car-sharing Vehicle Surcharge Application Changes
Financial
Form Gew-ta-rv-5 - General Excise/use, Employer's Withholding, Transient Accommodations And Rental Motor Vehicle & Tour Vehicle Surcharge Application Changes
Financial
Form Gew-ta-rv-5 - General Excise/use, Employer's Withholding, Transient Accommodations And Rental Motor Vehicle & Tour Vehicle Surcharge Application Changes - 2007
Financial
Form Gew-ta-rv-5 - General Excise/use, Employer's Withholding, Transient Accommodations And Rental Motor Vehicle & Tour Vehicle Surcharge Application Changes
Financial
Related Categories
Parent category: Legal