Claims made disclosure - Travelers
|[pic] |AUTO DEALER APPLICATION |
Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.
An Additional Information section is provided at the end of this document for any information that exceeds the space provided or attach any applicable document.
GENERAL INFORMATION
|Proposed First Named Insured And Other Named Insureds: |Today's Date: (mm/dd/yyyy): |
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|Mailing Address: |
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|Telephone Number: |Web Address: |
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|Type of Legal Entity: |Number of Years in Business: |
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|Proposed Effective Date (mm/dd/yyyy): |Proposed Expiration Date (mm/dd/yyyy): |
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TYPE OF DEALERSHIP INFORMATION
1. Indicate if Auto Dealer is: Franchised Non-Franchised
Enter a percentage for those that apply:
|Car | |% |
|Truck-Tractor | |% |
|Motorcycle | |% |
|Recreational Vehicle | |% |
|Snowmobile | |% |
|Other: | | |% |
2. Describe any secondary operations: (Mini Marts, day care, playgrounds, car wash, etc.)
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3. Do employees regularly use own autos on company business? Yes No
|If yes, include the number of employees and the description of use: |
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AUTO DEALER LOCATION INFORMATION
4. List all Auto Dealer locations:
|Location No. |Address – Street, City, State, Zip Code (State your main business location first) |Type of Operations |
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COVERED AUTOS* COVERAGE INFORMATION
*Coverage options are based on dealer’s headquartered state requirements.
|Coverage |Covered Auto Symbols |Limits |Deductibles |
|Liability | 21 22 23 24 27 28 29 |$ |$ |
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|Full Covered Autos Liability Limit for Customers |
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|Medical Payments | 21 22 23 24 27 28 29 |$ |$ |
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|Uninsured Motorist | 22 23 24 26 27 | CSL | BI EA PER $ |
| | |BI Each Accident |$ |
| | |Property Damage Ded |$ |
| | |Property Damage |$ |
|Underinsured Motorist | 22 23 24 26 27 | CSL | BI EA PER $ |
| | |BI EA Accident |$ |
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|Plates: |# Dealer/Transporter |# Transportation |
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|Personal Injury Protection | 25 27 |Each Person $ | Named Insured |
|Single Limit | | |Named Ins & Resident Relatives |
|Split Limit | | | |
| | |Ded $ | |
|Additional Personal Injury Protection | 25 27 |Each Person $ |Each Accident $ |
| | | Named Insured | Named Ins & Resident Relatives |
COVERED AUTOS STATE SPECIFIC COVERAGE INFORMATION
|Arkansas |
|Personal Injury Protection 25 27 |
|Medical Payments |Each Person $ |
|Work Loss |Accidental Death $ |
|Connecticut |
|Basic Reparations Benefits 25 27 |Limit $ |
|Added Reparations Benefits 25 27 |Per Week $ |
|District of Columbia |
|Personal Injury Protection 25 27 |Deductible $ |
| |Work Loss $ |
| |Medical Funeral $ |
|IOWA |
|Uninsured Motorist | 22 23 24 26 | CSL BI Each Person $ |
|Stacked |27 | |
|Non-Stacked | | |
| | |BI Each Accident $ |
|Kentucky |
|Motorcycle PIP 25 27 |$ Applies To Motorcycles Listed* |
|Named Individual Broadened PIP 25 27 |$ Applies To Individuals Listed* |
|Uninsured Motorist | 22 23 24 26 | CSL BI Each Person $ |
|Stacked |27 | |
|Non-Stacked | | |
| | |BI Each Accident $ |
|Underinsured Motorist | 22 23 24 26 | CSL BI Each Person $ |
|Stacked |27 | |
|Non-Stacked | | |
| | |BI Each Accident $ |
*List Motorcycles/Individuals In The Space Provided In The Additional Information Section.
|Maryland |
|Personal Injury Protection 25 27 |$2,500 Per Person |
| |Waiver Of PIP |
|Massachusetts |
|Compulsory Personal Injury Protection |Per Person $ |Deductible $ |
|25 27 | | |
| | Yourself Yourself & Family Members |
|Compulsory: Damage To Someone Else’s Property 21 22 23 24 27 28 29 |Each Accident $ |
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|Optional Medical Benefits |Each Person $ |
|21 22 23 24 27 28 29 | |
|Optional Medical Payments |Each Person $ |
|21 22 23 24 27 28 29 | |
|Compulsory Uninsured Motorist | CSL BI Each Person $ |
|21 22 23 24 26 27 |BI Each Accident $ |
| |Property Damage $ |
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|Underinsured Motorist | CSL BI Each Person $ |
|21 22 23 24 26 27 | |
| |BI Each Accident $ |
|Optional Bodily Injury To Others |Each Person $ |
|21 22 23 24 27 28 29 | |
| |Each Accident $ |
|Michigan |
|Limited Property 25 27 |Each Accident $1,000 |
|Property Protection 25 27 |Each Accident $1,000,000 |
|Minnesota |
|Personal Injury Protection 25 27 | $100 Med Exp Ded | $200 Work Loss Ded |
| | $100/$200 Med Exp Ded/ Work Loss Ded | No Deductible |
| | Work Loss Exclusion Named Ins Only, Age 65 Or Older, Or Age 60-64 & Retired & |
| |Receiving A Pension |
| | Work Loss Exclusion Named Ins & Any Family Member, Age 65 Or Older, Or Age 60-64|
| |& Retired & Receiving A Pension |
| | Work Loss Exclusion Any Family Member, Age 65 Or Older, Or Age 60-64 & Retired |
| |& Receiving A Pension |
|Additional PIP 25 27 |Work Loss $ |
| |Additional Medical Exp $ |
|MONTANA |
|Uninsured Motorist | 22 23 24 26 | CSL BI Each Person $ |
|Stacked |27 | |
|Non-Stacked | | |
| | |BI Each Accident $ |
|Uninsured Motorist | 22 23 24 26 | CSL BI Each Person $ |
|Stacked |27 | |
|Non-Stacked | | |
| | |BI Each Accident $ |
|New York |
|OBEL 25 27 |$ |
|Additional PIP 25 27 |$ |Work Loss $ |
| |Other Exp $ |Death Benefit $ |
|Work Loss Coord 25 27 | YES NO |
|Medical Exp Elim 25 27 | Named Ins Only |
| |Named Insured & Relatives |
|Statutory Uninsured Motorist | CSL BI Each Person $ |
|22 23 24 26 27 | |
| |BI Each Accident $ |
|Supplementary Uninsured / Underinsured Motorist (Sum) 22 23 24 26 27 | |
|North Dakota |
|Additional PIP 25 27 |Work Loss / Surviv Inc Loss $ |
| |Repl Svcs / Srv Rep Loss $ |
| |Funeral Exp $ |
| |Total Addl PIP Limit $ |
|New Jersey |
|Personal Injury Protection 25 27 |Health Insurance Option Yes No |
| |Medical Exp $ |
| |Deductible $ |
| |Ext Med Exp Each Person $ |
|Oregon |
|Personal Injury Protection 25 27 |$ Medical Exp Ded None $100 $250 Named Insured Named Ins & |
| |Family Members |
|Pennsylvania |
|First Party Benefits 25 27 |Med Exp $ |Funeral $ |
| |Work Loss $ |Acc Death $ |
|Combination First Party Benefits 25 27 |Total Benefit Limit $ |
| |Funeral $ |
| |Acc Death $ |
|Extraord Med Ben 25 27 |$ |
|South Dakota |
|Supplemental Auto Coverages 25 27 |Total Disability Benefits $ |
| |Auto Death Ben $10,000 Each Person |
| |$60 Per Person Gainfully Employed |
| |$30 Per Person – Not Gainfully Employed |
|UTAH |
|Personal Injury Protection 25 27 |Medical Exp $ |Inc Ben $ |
| | Waive Income Benefits |
| |Funeral Exp $ |Survivor Loss $ |
|Additional PIP 25 27 |Medical Exp $ |Inc Ben $ |
| | Waive Income Benefits |
| |Funeral Exp $ |Survivor Loss $ |
PHYSICAL DAMAGE INFORMATION
|*Physical Damage |
|Comprehensive | 22 23 24 27 28 31 |
|Specified Causes of Loss (describe coverage desired in the | 22 23 24 27 28 31 |
|Endorsements/Remarks section) | |
|Collision | 22 23 24 27 28 31 |
|Blanket Collision Limit |$ |Blanket Collision Deductible |$ |
*Complete Location Detail Information Section for all locations
|Coverages |Types of “autos” |Interest covered |
| |New |Used Autos, demonstrators and service vehicles |
|Additional locations where you store covered "autos" |$ |
|In Transit |$ |
Indicate Premium Basis: Non-reporting basis
Reporting basis: Quarterly Monthly
Endorsements / Remarks (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
| Auto Dealers Xtend Endorsement…………………..(CA T4 25) |
|Truck Dealer Extension Endorsement……………..(CA T3 63) |
|Fluctuating Values Endorsement……………………(CA T4 70) |
|Replacement And Repair……………………………...(CA T3 83) |
|Customer Complaint Legal Defense Coverage...... (CA T4 28) |
|Lemon Law Coverage…………………………………..(CA T3 58) |
|False Pretense Coverage………………………………(CA T4 57) |
| Other: (describe) |
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GENERAL LIABILITY COVERAGE INFORMATION
|Coverages |Limits |
|General Liability Bodily Injury And Property Damage Liability |$ |Each Accident |
|Damages To Premises Rented To You |$ |Any One Premises |
|Personal Injury And Advertising Injury |$ |Any One Person or Organization |
|General Liability (Aggregate) |$ | |
|Products And Work You Performed Aggregate |$ | |
|Locations And Operations Medical Payments |$ | |
| Acts Errors Or Omissions Liability Limits |$ |Aggregate |
| |$ |Per Claim Deductible |
| Acts Errors Or Omissions Coverage Extension (CA T4 26) |
| Acts Errors Or Omissions Limits Extension (CA T4 80) |
Is waste oil, etc. disposed of by outside firm with certificates? Yes No
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
ACORD 45 Attached for additional names
|Interest |Rank: |Name and Address |
| | |Scheduled Item Number: |
| | |Other |
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| |Item Description: |
LOCATION DETAIL INFORMATION
PROVIDE 13 MONTH OPERATING REPORT FOR EACH LOCATION TO WHICH COVERAGE WILL APPLY AND COMPLETE THE LOCATION DETAIL INFORMATION.
DRIVER INFORMATION – INCLUDE ALL FAMILY MEMBERS AND NON-EMPLOYEES
|Name, City, State, & |
|Zip Code |
6. Any Renting Operations other than to customers while vehicle is in for repair? Yes No
|If yes, explain: |
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7. Loaner Policy: (Describe controls such as minimum age, proof of insurance, etc.)
(If available, attach copy of the loaner/rental agreement)
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8. Dealer or factory sponsored loaners? Yes No
|If yes, explain: |
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9. Is Mfr responsible for liability on factory loaners? Yes No
|If yes, explain: |
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|10. Number of Dealer Loaners: | |
11. Any courtesy vans? Yes No
If yes, are any 15 passenger? Yes No
12. Describe any non-dealer Operations: (e.g. non-dealer operations such as vehicle conversions, truck body mfg., etc.)
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13. Any repair work on RVs, Buses, Fire Trucks, etc.? Yes No
If yes, do service operations include extraordinary work such as hydraulic repairs on heavy trucks,
special equipment, etc.? Yes No
|If yes, describe fully: |
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14. Do service operations include any installation, repair and/or service of fuel system conversions
(e.g. gasoline systems to CNG, Propane, Hydrogen, etc.)? Yes No
|If yes, explain: |
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15. Any spot delivery? Yes No
Define as either:
a. Releasing a vehicle to a customer prior to absolute final financing approval and sale or Yes No
b. Allowing potential customers to take vehicles off site unattended for prolonged test periods
(also known as puppy dogs)? Yes No
|If yes, who approves the release of vehicles for spot delivery? | |
|16. What is the number of vehicle delivery or Dealer Exchange trips > 50 miles? | |
17. Do you drive-away or haul-away vehicles from factory distributing point or other dealers? Yes No
18. Do you use tow trucks? Yes No
19. Do you pick-up or deliver customer’s vehicles? Yes No
PLATE INFORMATION
20. Dealer Plate Controls:
|a. Number of permanent plates (parts trucks, tow trucks, etc.) | |
|b. Number of dealer plates used for demos, loaners, and test drives | |
|c. Number of spare dealer plates | |
|d. Total number of dealer plates (subject to audit): | |
21. List the names of whom Dealer plates are assigned to:
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|22. How are spare dealer plates used? | |
|23. How are dealer plates secured to avoid theft? | |
DEMO EXPOSURES INFORMATION
|24. How many of your sales staff have demos assigned to them? | |
25. List the names of whom demo vehicles are assigned to:
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26. Describe your Personal use policy for demo vehicles:
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27. List all family members, any non-employee drivers and any driver under the age of 25 who operate vehicles and their relationship to the insured:
|Name |Relationship |
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28. Do you allow test drives of vehicles? Yes No
|If yes, describe: |
29. Do you allow test drives of motorcycles? Yes No
|If yes, describe: |
30. Any racing activities or race vehicle sponsorship? Yes No
|If yes, describe: |
31. Any towing or roadside assistance provided by the insured? (If subbed out, answer No) Yes No
|If yes, describe: |
32. Any trucks capable of towing multiple autos? Yes No
33. Any unusual items taken in for trade? Yes No
|If yes, describe items: |
34. Do you have parts delivery operation? Yes No
If yes, indicate (regularly scheduled) or (not regularly scheduled) and describe parts delivery.
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|35. What is the radius of parts delivery? Miles: | |
36. Does the dealer have a body shop? Yes No
|If yes, describe fire protection: |
37. Do you perform spray painting or welding? Yes No
38. Are all flammables properly protected? Yes No
***Complete Full Property ACORD App***
INSURANCE AGENT'S E&O INFORMATION
39. Other than credit life, Accident & Health etc., do you sell P&C insurance? …………………… Yes No
|If yes, describe: |
40. Are any companies with A.M. Best’s rating of lower than A- represented? …………………… Yes No
41. Any E&O losses in past 5 years? …………………… Yes No
|If yes, describe: |
TITLE AND STATUTORY E&O (If Requested)
42. Describe process for Title Searches:
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43. Is there a documented procedure in place for compliance with laws relating to Title, Odometer,
Prior Damage, Used Vehicle Sales, Parts Sales, Lending, Leasing? Yes No
44. Has training been provided to sales and finance employees in compliance with statutes? Yes No
45. Do you keep detailed records of customers’ prior damage and product complaints? Yes No
46. Do you use an outside firm to confirm prior damage, mileage, title? Yes No
47. Do you require customer signature acknowledging the disclosure of prior damage, title,
odometer and buyers guide? Yes No
48. Are all customer forms and media advertisements relating to financing approved by counsel? Yes No
49. Do you have a conspicuous, clear, two-sided and well understood Arbitration Agreement
built into your vehicle sales contracts? Yes No
50. Are you aware of any E&O losses or complaints or allegations that might give rise to a law suit in
past 5 years? Yes No
|If yes, describe: |
51. Describe all Product Defense claims in the last 5 years:
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SCHEDULE OF COVERED AUTOS FURNISHED TO SOMEONE OTHER THAN CLASS I OR CLASS II OPERATORS OR WHICH ARE INSURED ON A SPECIFIED CAR BASIS
|Covered Auto No.|Town, State, and Zip Code Where Auto will be Principally Garaged: |
|1 | |
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|Year, Make, & Model: |Size GVW/GCW or Seat |Vehicle ID Number (VIN) |Original Cost New |Rating Class Code |
| |Capacity | | | |
| | | |$ | |
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|Basic PIP |Added PIP |Property Protection |Medical Payments |
|Covered Autos Liability |Deductible | | | |
|$ |$ | | |$ |
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|*Limit of Insurance |Comprehensive Deductible |Specified Causes of Loss Deductible |Collision Deductible |
|$ |$ |$ |$ |
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|Indicate either “ACV” or Stated Amount |
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|Covered Auto No.|Town, State, and Zip Code Where Auto will be Principally Garaged: |
|2 | |
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|Year, Make, & Model: |Size GVW/GCW or Seat |Vehicle ID Number (VIN) |Original Cost New |Rating Class Code |
| |Capacity | | | |
| | | |$ | |
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|Basic PIP |Added PIP |Property Protection |Medical Payments |
|Covered Autos Liability |Deductible | | | |
|$ |$ | | |$ |
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|*Limit of Insurance |Comprehensive Deductible |Specified Causes of Loss Deductible |Collision Deductible |
|$ |$ |$ |$ |
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|Indicate either “ACV” or Stated Amount |
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|Covered Auto No.|Town, State, and Zip Code Where Auto will be Principally Garaged: |
|3 | |
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|Year, Make, & Model: |Size GVW/GCW or Seat |Vehicle ID Number (VIN) |Original Cost New |Rating Class Code |
| |Capacity | | | |
| | | |$ | |
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|Basic PIP |Added PIP |Property Protection |Medical Payments |
|Covered Autos Liability |Deductible | | | |
|$ |$ | | |$ |
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|*Limit of Insurance |Comprehensive Deductible |Specified Causes of Loss Deductible |Collision Deductible |
|$ |$ |$ |$ |
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|Indicate either “ACV” or Stated Amount |
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|Covered Auto |Loss Payee (The number opposite each entry indicates the auto to which the entry applies, such auto being identified by the same number above) |
|1 | |
|2 | |
|3 | |
|Covered Auto |Person or Organization To Which The Covered Auto Has Been Furnished (Do not include Covered Autos which have been furnished to Class I or Class II |
| |operators) |
|1 | |
|2 | |
|3 | |
HIRED OR BORROWED PHYSICAL DAMAGE COVERAGE INFORMATION
|Coverage |State(s) |Deductible |Estimated Annual Cost of Hire For Each State (Excluding Autos|
| | | |Hired with a Driver) |
| Comprehensive | |$ |$ |
| Specified Causes of Loss | |$ |$ |
| Collision | |$ |$ |
For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website:
If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Agency Compensation, One Tower Square, Hartford, CT 06183.
This application, including any material submitted in conjunction with this application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Travelers. It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.
FRAUD STATEMENTS – ATTENTION APPLICANTS IN THE FOLLOWING JURISDICTIONS
ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KANSAS: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer or insurance agent or broker, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.
KENTUCKY, NEW JERSEY, NEW YORK (OTHER THAN AUTO INSUREDS), OHIO, AND PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other 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 and subjects such person to criminal and civil penalties. (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.)
AUTO INSUREDS IN NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other 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, and any person who in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.)
LOUISIANA, MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
SIGNATURES
Producer information only required in Florida, Iowa, and New Hampshire.
|Authorized Representative Signature*: |Authorized Representative Name – Printed: |Date (mm/dd/yyyy): |
|x | | |
|Producer Signature*: |State Producer License No (required in FL): |Date (mm/dd/yyyy): |
|x | | |
|Agency: |Agency Contact: |Agency Phone Number: |
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* If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.
Electronic Signature and Acceptance – Authorized Representative
Electronic Signature and Acceptance – Producer
ADDITIONAL INFORMATION
This area may be used to provide additional information to any question. Please reference the question number.
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