Commercial Vehicle Insurance-converted

Name of your company or Your name*
Your Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3. AUTOMOBILE LIST
Automobile Details*
Year Make Model Serial Number Current Market Value Purchase Month/ Year Use
COMMODITIES TRANSPORTED
(if vehicle carries explosives, nuclear/radioactive material or dangerous goods, identify which goods are carried and complete, sign and attach appropriate questionnaire)
MERCHANDISE CARRIED AND PERCENTAGE USE REMARKS SECTION IF MORE SPACE REQUIRED
(%) (%) (%)
HAULING FOR OTHERS
HAULING DONE FOR OTHERS? IF SO, PROVIDE FREQUENCY*
- NEVER
- DAILY
- WEEKLY
- MONTHLY
RADIUS OF OPERATION
NORMAL OPERATING DISTANCE - ONE WAY*
% OF TOTAL TRIPS*
MAXIMUM OPERATING DISTANCE - ONE WAY*
% OF TOTAL TRIPS*
NO. OF TRIPS PER MONTH BEYOND THE NORMAL DISTANCE FROM PLACE USUALLY KEPT*
MOST COMMON DESTINATIONS - LIST CITIES AND PROVINCES. USE REMARKS SECTION IF MORE SPACE IS REQUIRED*
U.S.A. EXPOSURE
ANY U.S.A. EXPOSURE?
- Yes
- No
MOST COMMON DESTINATIONS - LIST CITIES AND STATES*
NUMBER OF KILOMETERS FROM THE BORDER*
NUMBER OF TRIPS PER MONTH*
NUMBER OF CONSECUTIVE DAYS*
ANNUAL USE %*

4. NON-OWNED VEHICLES/TRAILERS
DOES THE APPLICANT NEED 27/27B LIABILITY FOR DAMAGE TO NON-OWNED VEHICLES?*
- Yes
- No
HAS LIABILITY BEEN ASSUMED UNDER CONTRACT OR AGREEMENT?*
- Yes
- No
NON-OWNED VEHICLES/TRAILERS*
TYPE OF NON-OWNED VEHICLE / TRAILER AVERAGE NO. OF VEHICLES/TRAILERS AT ANY ONE TIME AVERAGE VALUE MAXIMUM NO. OF VEHICLES/TRAILERS ANNUALLY VALUE OF THE MOST EXPENSIVE UNIT
ARE ANY OF THE INSURED VEHICLES USED FOR PUBLIC TRANSPORTATION? (DRIVING SCHOOL, PRIVATE OR PUBLIC BUSES, TAXIS, LIMOUSINES, FUNERAL, OR EMERGENCY VEHICLES)*
- Yes
- No
IF YOU HAVE PUBLIC VEHICLES, PLEASE COMPLETE THE PUBLIC COMMERCIAL VEHICLE SUPPLEMENT.

5. REMARKS
REMARKS
THIS SUPPLEMENTAL APPLICATION IS INTENDED TO PROVIDE INFORMATION IN ADDITION TO THAT PROVIDED WITHIN THE CORRESPONDING OWNER'S APPLICATION FORM. CONSENT AND DISCLOSURE PROVIDED WITHIN THE CORRESPONDING OWNER'S APPLICATION FORM EXTEND TO THIS SUPPLEMENTAL APPLICATION, AND THE APPLICANT ACKNOWLEDGES THAT THE APPLICATION FOR A CONTRACT OF INSURANCE IS BASED ON THE TRUTH OF THE INFORMATION PROVIDED HEREIN.
Date*
CAPTCHA

TYPE OF NON-OWNED VEHICLE / TRAILER	AVERAGE NO. OF VEHICLES/TRAILERS AT ANY ONE TIME	AVERAGE VALUE	MAXIMUM NO. OF VEHICLES/TRAILERS ANNUALLY	VALUE OF THE MOST EXPENSIVE UNIT

1. BUSINESS OF INSURED