Form 62695 - Vehicle Insurance Application Form - Small Fleet Insurance Application Page 2
ADVERTISEMENT
1
2EQUIPMENT INFORMATION
Unit
Owned?
P=
Model
Make
Model
Type *
Serial Number
Physical
Stated
Leased?
Power
Year
Damage
Amount
Owner/
Unit
Deduc-
Oper.
T=
tible**
Trailer
1
/ / / / / / / / / / / / / / / /
2
/ / / / / / / / / / / / / / / /
3
/ / / / / / / / / / / / / / / /
4
/ / / / / / / / / / / / / / / /
5
/ / / / / / / / / / / / / / / /
6
/ / / / / / / / / / / / / / / /
*-
Tractor Type = Cabover, Conventional, Straight Truck, Service, Other (Describe)
Trailer Type = Van, Van Refrig., Tank - Liquid, Dry Bulk, Gas Bulk, Flatbed, Lowboy
**Enter N/A if no physical damage requested.
LIST OF COMMODITIES HAULED (INCLUDING BACKHAULED COMMODITIES)
Type
Revenue %
Type
Revenue %
LOSS HISTORY
Prior Carrier
Period
Losses (attach separate sheet if necessary)
MISCELLANEOUS QUESTIONS
Does applicant haul double trailers and/or triple trailers?
_______Yes
______No
For NTU coverage, is the truck under permanent lease?
_______Yes
______No
(Attach copy of lease if so)
Does the applicant act as a truck broker?
_______Yes
______No
Does the named applicant operate any other vehicles not listed?
_______Yes
______No
Are placards ever required for any vehicle?
_______Yes
______No
COMMENTS
Explain any yes answers or give details on losses in space following?___________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_________________________________________________________________________________________________________
BROKER INFORMATION
Broker Name and Address:___________________________________________ Phone #:______________________
__________________________________________________________________
Fax #: ______________________
__________________________________________________________________
__________________________________________________________________
Broker Signature____________________________________________________
APPLICANT'S STATEMENT
AIG
I hereby apply to
Truck Insurance Group for a policy of insurance as set forth in this application on the basis of statements
contained herein.
Signature of Applicant ______________________________________________
Date _____/_____/_____
Insurance provided by Member Companies of American International Group, Inc.
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