Chubb Group of
Insurance Companies
Continuum From Chubb
Timely Liability Solutions
Applications for:
Discontinued Products Liability Insurance
Successor Liability Insurance
Retroactive Liability Insurance
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
APPLICATION FOR CONTINUUM
LIABILITY INSURANCE
____________________________________________________________________________________________________
GENERAL INFORMATION
1.
a.
Applicant Name: __________________________________________________________________________________
b.
Mailing Address: __________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
c.
Website Addresses: _________________________________________________________________________________
d.
Applicant is:
corporation
joint venture
partnership
individual
other (describe):_________
___________________________________________________________________________________________________
e.
If publicly traded, symbol/exchange: ____________________________________________________________________
f.
Year business established: __________
g.
Is Applicant a subsidiary of another organization?
Place of incorporation/organization: ___________________________
Yes
No
If yes, explain:_______________________________________________________________________________________
h.
Has any legal or trade name of the Applicant changed (including the last 10 years)?
Yes
No
If yes: ______________________________________________________________________________________
I.
Any bankruptcies or liens against the Applicant or other parties to the transaction?
Yes
No
If yes: ______________________________________________________________________________________
2.
Producer: ___________________________________________________________________________ Number: _______________
3.
Has any insurer ever cancelled or refused to renew any coverage?
Yes
No
If yes, explain:
_______________________________________________________________________________________
_______________________________________________________________________________________
TRANSACTION INFORMATION
Describe the circumstances or transactions leading to this Application for insurance. Include separate
attachments as necessary. _____________________________________________________________________________________________
_____________________________________________________________________________________________
Applicant’s role in the transaction:
Buyer
Seller
other (explain): ____________
Describe the transaction:
discontinuation of business or product or service line
total purchase/sale or merger
purchase or sale of all or substantially all assets of the acquired entity
purchase or sale of less than substantially all assets of the acquired entity
other (describe): ____________________________________________________________________________
Page 2 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
__________________________________________________________________________________________________________________________
COVERAGE REQUEST
Limit requested (all coverages subject to
a single Aggregate Limit Of Insurance):
General Liability
products liability
____________________________ Aggregate
premises / operations liability
________________________
other: _______________
___________________________
Deductible / Retention requested:
___________________________ Each Claim / Event
Excess Liability
Limit requested (all coverages subject to
a single Aggregate Limit Of Insurance):
products liability
___________________________ Aggregate
premises / operations liability
___________________________
automobile liability
.
___________________________
employer’s liability
___________________________
other: _____________________
___________________________
Excess Liability - Please complete and attach Schedules Of Underlying Insurance as requested herein.
_________________________________________________________________________________________________________________________
Injury or Offense Period
Claim Reporting Period
Injury or Offense Period is the period during which a covered injury or
offense would occur (future) or would have occurred (past).
Claim Reporting Period is the period during which the first report of a covered claim
would be made (future) to the insured or insurer (in no case earlier than the date we
agree to bind coverage).
From: __________________
From: __________________
To:
To:
__________________
__________________
__________________________________________________________________________________________________________________________
EXPOSURE INFORMATION
1.
Describe all businesses, operations and products (current and prior) potentially exposing the Injury or Offense Period including
complete descriptions of all applicable entities. Include separate attachments as necessary.
Page 3 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
__________________________________________________________________________________________________________________________
2.
Describe any assets, businesses, entities, operations, products or services that have been (or to be) discontinued, divested or
sold (including the last 10 years). Indicate year discontinued, divested or sold as well as expected product/project life spans
and quantify the number of products/projects estimated still viable and in use. Include separate attachments as necessary.
Year
3.
Transaction Type / Description
Product / Project Life Span
Cumulative Amount Still Viable
And In Use
With respect to any discontinued, divested or sold assets, businesses, entities, operations, products or services, describe any
liabilities that have been assumed or retained by the Applicant.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4.
If liabilities have been assumed by or transferred to others, describe by whom, how and the extent to which such others
are responsible.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
5.
If coverage is requested in connection with operations or products of an entity that has been (or to be) discontinued, divested
or sold by the Applicant, then indicate if coverage is to apply only to the Applicant as “the insured” or to both the Applicant
and the acquiring entity as “insureds”?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
6.
Describe and quantify any incomplete or unsold inventory at the time of this transaction. Indicate the disposition plans for
any such inventory.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Page 4 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
__________________________________________________________________________________________________________________________
SALES: List sales for each year of the Injury or Offense Period.
YEAR
U.S.A. / CANADA SALES
OTHER COUNTRY SALES
TOTAL SALES
# OF UNITS
Name other countries by sales volumes: ______________________________________________________________________________
________________________________________________________________________________________________________________
PRODUCTS - Please explain all answers as requested. Include separate attachments as necessary.
Attach copies of product brochures/catalogues and marketing materials (current and those used during the Injury or Offense Period.)
1.
Expected product life spans: _____Years
_____Months.
Explain: __________________________________________________________________________________________________
2.
Yes
No
Any products or services in connection with aircraft/aerospace or watercraft?
If yes: ____________________________________________________________________________________________________
3.
Any products used in connection with automobiles, other vehicles or mobile equipment?
Yes
No
If yes: ____________________________________________________________________________________________________
4.
Yes
No
Any products or services in connection with nuclear or other energy-related facilities?
If yes: ____________________________________________________________________________________________________
5.
Yes
No
Explosive or flammable products?
If yes: ___________________________________________________________________________________________________
6.
Contaminative, pathogenic, toxic / poisonous or other pollutant or hazardous products?
Yes
No
If yes: ___________________________________________________________________________________________________
7.
Yes
No
Any products containing asbestos, silica, lead or other hazardous materials?
If yes: ___________________________________________________________________________________________________
8.
Yes
No
Any workplace safety products or services?
If yes: ___________________________________________________________________________________________________
9.
Any drug, medical device, dietary supplement or cosmetics related products or services?
Yes
No
If yes: ___________________________________________________________________________________________________
Page 5 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
__________________________________________________________________________________________________________________________
Yes
No
10.
Any alcohol, firearm or tobacco related products or services?
If yes: ___________________________________________________________________________________________________
11.
Any children’s products or services?
Yes
No
If yes: ___________________________________________________________________________________________________
12.
Yes
No
Foreign sourced products distributed in the U.S.A., or used as components / ingredients?
If yes: ___________________________________________________________________________________________________
13.
Any products or services discontinued (including for safety or other reasons)?
Yes
No
If yes: ___________________________________________________________________________________________________
CONTRACTS / INSTALLATIONS / SERVICE WORK - Please explain all answers as requested.
Include separate attachments as necessary.
1.
Describe any installation, repair, service or other contract work. Include separate attachments
as necessary, listing projects and related revenues for the last 10 years.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2.
Yes
No
All contract work by Applicant or with subcontractors supported by formal written contracts?
If no, why not? __________________________________________________________________________________________
3.
Yes
No
Any work subcontracted to others?
If yes, describe what types and amount work?:________________________________________________________________
________________________________________________________________________________________________________
4.
Yes
No
All contracts with subcontractors, suppliers and vendors reviewed by legal counsel?
If no, why not?:___________________________________________________________________________________________
5.
All contracts with subcontractors and suppliers require indemnity to the Applicant and holding
Yes
No
the Applicant harmless from legal action?
If no, explain: ___________________________________________________________________________________________
6.
Subcontractors and suppliers required to carry insurance (at least GL and
Yes
No
Workers Compensation)?
If yes, what types / limits? _________________________________________________________________________________
If no, why not? __________________________________________________________________________________________
7.
Subcontractors and suppliers required to provide the Applicant with “insured” status
Yes
No
on their insurance?
If no, explain: ___________________________________________________________________________________________
8.
Subcontractors and suppliers required to provide certificates of insurance to the Applicant?
Yes
No
If no, explain: ___________________________________________________________________________________________
9.
Yes
No
Any construction, demolition or structural alteration work?
If yes: _________________________________________________________________________________________________
10.
Yes
No
Blasting, earth moving, excavation, mining or other underground work?
If yes: _________________________________________________________________________________________________
11.
Maritime, reservoir or other waterway or water supply work?
Yes
No
If yes: _________________________________________________________________________________________________
12.
Yes
No
Bridge, dam, railroad or tunnel work?
If yes: _________________________________________________________________________________________________
Page 6 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
_________________________________________________________________________________________________________________________
Yes
No
13.
Any work involving asbestos, silica, lead or other pollutants or hazardous materials?
If yes: _________________________________________________________________________________________________
14.
Architects, engineers, surveyors or other professionals employed or contracted?
Yes
No
If yes: _________________________________________________________________________________________________
POLLUTION - Please explain all answers as requested. Include separate attachments as necessary.
1.
Any environmental or regulatory agency (U.S.A. or otherwise) identified or investigated any party
Yes
No
as a generator, transporter, storer, treater or disposer of hazardous materials?
If yes: _________________________________________________________________________________________________
2.
Yes
No
Any underground storage tanks at any location (current or past)?
If yes: _________________________________________________________________________________________________
3.
Any landfills or other waste facilities?
Yes
No
If yes: _________________________________________________________________________________________________
OTHER EXPOSURES - Please explain all answers as requested. Include separate attachments as necessary.
1.
Aircraft owned?
Yes
No
Non-owned Aircraft?
Yes
No
If yes: _________________________________________________________________________________________________
2.
Watercraft owned?
Yes
No
Non-owned Watercraft?
Yes
No
If yes: _________________________________________________________________________________________________
3.
Yes
No
Ownership, operation, maintenance or use of any railroad or rail equipment?
If yes: _________________________________________________________________________________________________
4.
Any exposure to nuclear/radioactive or other hazardous materials?
Yes
No
If yes: _________________________________________________________________________________________________
5.
Yes
No
Any uses of genetic engineering or nanotechnology?
If yes: _________________________________________________________________________________________________
6.
Yes
No
Any healthcare professionals employed or contracted or health care facilities?
If yes: _________________________________________________________________________________________________
7.
Any law enforcement or security services?
Yes
No
If yes: _________________________________________________________________________________________________
8.
Yes
No
Any accounting or legal services?
If yes: _________________________________________________________________________________________________
9.
Any financial or insurance services?
Yes
No
If yes: _________________________________________________________________________________________________
10.
Yes
No
Any independent contractors engaged?
If yes: _________________________________________________________________________________________________
11.
Yes
No
Any employees/workers contracted from or to another entity?
If yes: _________________________________________________________________________________________________
12.
Any liability assumed under contract or agreement?
Yes
No
If yes: _________________________________________________________________________________________________
13.
Yes
No
Child care or other special care facilities operated or sponsored?
If yes: __________________________________________________________________________________________________
Page 7 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
___________________________________________________________________________________________________________
14.
Any business or operations located outside the U.S.A.?
Yes
No
If yes: __________________________________________________________________________________________________
15.
Any special events or sponsored activities?
Yes
No
If yes: __________________________________________________________________________________________________
LOSS PREVENTION/PRODUCT RECALL PLANS AND CONTROLS
Please explain all answers as requested. Include separate attachments as necessary.
1.
Does the Applicant have in place formal Loss Prevention and Quality Control Programs?
Yes
No
Attach copies of programs or explain below.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2.
Yes
No
All advertising materials, instruction manuals, packaging and warning labels reviewed by
legal counsel?
If no, why not?:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
3.
Describe how to identify and distinguish products from similar (competitors) products at time of loss:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4.
Describe how to identify and quantify products by date of manufacture and sale at time of loss:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
5.
Does the Applicant maintain records of:
a) when and where products were manufactured
b) to whom products were sold and the date of sale
c) who supplied components and ingredients going into products
d) quality control and product/material tests
Yes
Yes
Yes
Yes
No
No
No
No
Describe record keeping practices: by whom, where and for how long records are maintained, including
maintenance and access in the FUTURE (after the transaction): ___________________________________
__________________________________________________________________________________________
______________________________________________________________________________________________________
6.
Does the Applicant have in place formal Product Recall Plans?
Yes
No
Describe formal plans for handling FUTURE (after the transaction) customer claims,
communications and complaints, and product recalls. Attach copies of programs or explain below.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
7.
Any products ever recalled, withdrawn or suspended from use (voluntarily or involuntarily)
due to actual or potential defects or safety reasons, including provisions of information or
material for retro fitting?
Yes
No
If yes, describe recall / retro fit actions and percent of products actually recovered / retro fit:______________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Page 8 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
_________________________________________________________________________________________________________________
8.
Describe formal plans for handling FUTURE (after the transaction) maintenance, repair, service and warranty work:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
____________________________________________________________________________________________________
LOSS EXPERIENCE
Please explain all answers as requested. Include separate attachments as necessary.
1.
Is the Applicant aware of any circumstances, injuries or offenses that might lead to a claim
Yes
No
or suit being filed, including losses arising out of discontinued, divested or sold businesses or
operations, or products no longer manufactured or sold?
If yes: __________________________________________________________________________________________________
2.
Any judgments or settlements that are sealed or not disclosed within this Application?
Yes
No
If yes: __________________________________________________________________________________________________
3.
Any current or past administrative, civil or criminal investigation or litigation by any
Yes
No
governmental or regulatory authority?
If yes: __________________________________________________________________________________________________
4.
Describe any individual claims and losses greater than U.S.A. $10,000. Include the date and nature of loss and amounts
reserved and paid (including amounts within any deductible/retention and loss adjustment/defense expenses) and the
current status (closed or open). Include separate attachments as necessary. _______________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
LOSS EXPERIENCE SCHEDULES
Provide aggregate loss experience in the Loss Experience Schedules for each year of the Injury or Offense Period or the last
10 years, whichever is greater. Include amounts within any deductibles/retentions and loss adjustment/defense expenses.
Attach loss reports from prior insurers
YEAR
CLAIMS/LOSSES
COUNT
AMOUNT RESERVED
AMOUNT PAID
TOTAL INCURRED
Page 9 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
_________________________________________________________________________________________________________________________
OTHER LOSS EXPERIENCE - Please explain. Include auto liability, employer’s liability and other loss experience if requesting excess liability
insurance for such other exposures.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
____________________________________________________________________________________________________
FINANCIAL / TRANSACTION INFORMATION
1.
Attach copies of audited financial statements and other pertinent financial information for the most recent year and each year of
the Injury or Offense Period.
2.
Describe any businesses, operations and products not consolidated within the financial information submitted that the Applicant
is currently or has been involved with (including any contract work, investments, joint ventures, partnerships, etc.).
Include separate attachments as necessary.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3.
As part of this Application, please attach copies of:
x
Purchase/sale/acquisition/merger transaction agreements, including all schedules, exhibits and disclosure
statements
x
Letters of intent, prospectus, side agreements and letters relating to the transaction
PRIOR INSURANCE INFORMATION
Attach copies of policies, including endorsements.
Policy Period
Insurer
Premium
Limits
Deductible/Retention
Any prior coverage on a claims-made basis?
Yes
No
If yes, describe (including Retroactive Dates and status of Extended Reporting Periods):
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Page 10 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
_________________________________________________________________________________________________________________________
ANY CLAIMS ARISING OUT OF CIRCUMSTANCES KNOWN TO YOU (WHICH OTHERWISE
WOULD BE LIKELY TO GIVE RISE TO A CLAIM UNDER THE PROPOSED INSURANCE)
ARE EXCLUDED FROM COVERAGE UNDER ANY EVENTUAL INSURANCE WE MAY
PROVIDE.
COMPLETION OF THIS APPLICATION DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF
THE COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.
____________________________________________________________________________________________________________
CERTIFICATION
The undersigned persons declare that to the best of their knowledge the statements set forth above and in any attachments to this APPLICATION are
true and correct, and that every reasonable effort has been made to obtain sufficient information to facilitate the proper and accurate completion of
this APPLICATION. The undersigned agree that if any significant change in the condition of the Applicant is discovered between the date of this
APPLICATION and the effective date of the policy which would render this APPLICATION inaccurate or incomplete, notice of such change will
be reported in writing to the COMPANY immediately and, if necessary, any outstanding quotation may be modified or withdrawn. The undersigned
persons understand and further agree that the completion and signing of this APPLICATION neither binds the COMPANY to sell nor the Applicant
to purchase the insurance.
PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO
SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO
COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE.
False Information:
Any person who, knowingly and with intent to defraud an insurance company or other person, files an Application for insurance containing any false
information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which
is a crime.
False Information (California Only):
For your protection, California law requires the following to appear on this form:
Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
False Information (Colorado Only):
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.
False Information (Florida Only):
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.
False Information (Louisiana Only):
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
Application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
False Information (Maine Only):
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines or a denial of insurance benefits.
Page 11 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
______________________________________________________________________________________________________________________
False Information (Nebraska Only):
Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any
false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act,
which is a crime, where such person subsequently submits a claim.
False Information (New Mexico Only):
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
Application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
False Information (New York Only):
Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any
materially false information, or conceals information concerning any material fact thereto, for the purpose of misleading, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
False Information (Ohio Only):
Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an Application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
False Information (Oklahoma Only):
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance
policy containing any false, incomplete or misleading information is guilty of a felony.
False Information (Oregon Only):
Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any
false information, or conceals for the purpose of misleading information containing any material fact thereto, may be guilty of a insurance fraud.
False Information (Pennsylvania Only):
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 material fact thereto,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
False Information (Vermont Only):
Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any
false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act,
and the policy may be voided.
False Information (Virginia Only):
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance
company. Penalties include imprisonment, fines, and denial of insurance benefits.
____________________________________________
Applicant's Name/Legal Representative (print)
___________________________
Title
____________________________________________
Applicant Signature
___________________________
Date
____________________________________________
Producer Name (print)
___________________________
Title
____________________________________________
Producer Signature
___________________________
Date
Page 12 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
________________________________________________________________________________________________________________________
Excess Liability Insurance
Schedules Of Underlying Insurance
If requesting Excess Liability Insurance, please complete copies of this Schedule for EACH year of the Injury or Offense Period.
Attach additional Schedules as necessary.
YEAR________
Describe Others
Prem/Ops
Liability
Products/C.O.
Liability
Pers./Adv.
Liability
Occurrence
Claims-Made
Occurrence
Claims-Made
Occurrence
Claims-Made
Auto
Liability
Employer's
Liability
Insurer
Policy No.
Policy
Period
Annual
Premium
Type
Occurrence
Claims-Made
Occurrence
Claims-Made
Retro
Date
ERP?
Limits
Of
Insurance
$
Occurrence
$
Aggregate
$
$
Occurrence
$
Aggregate
$
Aggregate
Accident
$
Claim / Event
$
Aggregate
$
Claim / Event
$
Aggregate
$
$
$
$
$
$
Aggregate
$
Aggregate
$
$
$
$
per
loc/project: Y/N
Deductible/
Retention
$
Claim / Event
$
Aggregate
$
$
$
Please explain all answers as requested. Include separate attachments as necessary.
1.
Yes
No
Defense/supplementary payments reduce any limits of insurance?
If yes, describe: ________________________________________________________________________________________
2.
Any coverage extensions: pollution, product recall, etc.?
Yes
No
If yes, describe: ________________________________________________________________________________________
Attach copies of all proposed underlying policies, including endorsements.
Page 13 of 14
Chubb Group of Insurance Companies
15 Mountain View Road, Warren, NJ 07059
__________________________________________________________________________________________________________________________
Excess Liability Insurance
Autos Schedule
If requesting Excess Liability Insurance for Auto Liability, please complete this Schedule.
List number of units for each year of the Injury or Offense Period.
TYPE OF UNIT / YEAR
Private Passenger
Light Trucks
Medium Trucks
Heavy Trucks
Extra Heavy
Trucks/Tractors
Buses
Other, describe
TOTAL
Please explain all answers as requested. Include separate attachments as necessary.
Yes
No
1. Caustics, explosives, flammables, waste or other hazardous materials transported?
If yes: ______________________________________________________________________________________________________
Yes
No
2. Passengers transported for a fee?
If yes: ______________________________________________________________________________________________________
3. Any drivers not covered by Workers Compensation insurance?
Yes
No
If yes: ______________________________________________________________________________________________________
Yes
No
4. Any auto liability assumed under contract?
If yes: ______________________________________________________________________________________________________
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