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Auto Application

Proposed Effective Date:    
Applicant's Name:    
Auto Liability Limits Desired: $300,000 CSL $500,000 CSL $1,000,000 CSL
Uninsured Motorist: $20,000 $100,000 Other
Comp/Collision Deductible: $500/$500 $1,000/$1,000  
Med Pay: $2,000 $5,000 Other
Radius of Operations:  miles    
Do owners/ officers have personal auto insurance coverage? Yes No
If not, DOC required on:

Year / Make Model: VIN: Cost:

Name: DOB State License Number

Current Year: Company Losses
1st Prior Year Company Losses
2nd Prior Year Company Losses
3rd Prior Year Company Losses
In order to apply for rate experience discounts, please list insurance carriers for the past four (4) years.