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Policy Info




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Additional Information

Additional Information #1

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Additional Information #2

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Additional Information #3

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Policy Coverage


Driver Information



Add Drivers

**must include owner

Driver #{{driverinfo.id}}

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Vehicle Information


Vehicle #{{vehicle.id}}

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Prior Insurance Information


Add Prior Insurance

Prior Insurance Info #{{priorinfo.id}}

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Loss History

Remove

Loss Runs

Loss Run 1 :

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Loss Run 2 :

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Loss Run 3 :

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Loss Run 4 :

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Policy Info    Edit

{{quote.applicantinfo.apname}}
{{quote.applicantinfo.conname}}
{{quote.applicantinfo.Aplphone}}
{{quote.applicantinfo.Aplemail}}
{{quote.applicantinfo.address}}
{{quote.applicantinfo.insurecity}}


{{quote.applicantinfo.insurestate}}
{{quote.applicantinfo.insurezip}}
{{quote.applicantinfo.mailaddr}}
{{quote.applicantinfo.mailcity}}
{{quote.applicantinfo.mailstate}}
{{quote.applicantinfo.mailzip}}
{{quote.applicantinfo.legalentity}}
{{quote.applicantinfo.business_type}}
{{quote.applicantinfo.business_started_date_month}}/{{quote.applicantinfo.business_started_date_day}}/{{quote.applicantinfo.business_started_date_year}}
{{quote.applicantinfo.Years_in_Business}}
{{quote.applicantinfo.feinno}}
{{quote.applicantinfo.natureofbusiness}}
{{quote.applicantinfo.Description_of_Business}}
{{quote.applicantinfo.desired_from_date_month1}}/{{quote.applicantinfo.desired_from_date_day1}}/{{quote.applicantinfo.desired_from_date_year1}}
{{quote.applicantinfo.desired_to_date_month1}}/{{quote.applicantinfo.desired_to_date_day1}}/{{quote.applicantinfo.desired_to_date_year1}}
0-100 miles
101-300 miles
301-500 miles
501+ miles
Interstate,
Intrastate
{{quote.applicantinfo.metro_selected}}
{{quote.applicantinfo.other_city}}
{{quote.applicantinfo.is_AnyBankruptcies}}
Additional Information
Additional Information #1

{{quote.applicantinfo.from_date_month}}/{{quote.applicantinfo.from_date_day_2}}/{{quote.applicantinfo.from_date_year}}
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{{quote.applicantinfo.Resolution_Date_month}}/{{quote.applicantinfo.Resolution_Date_2}}/{{quote.applicantinfo.Resolution_Date_year_2}}
Additional Information #2

{{quote.applicantinfo.from_date_2_month}}/{{quote.applicantinfo.from_date_2_day_2}}/{{quote.applicantinfo.from_date_2_year}}
{{quote.applicantinfo.Explanation_2}}
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{{quote.applicantinfo.Resolution_month_2}}/{{quote.applicantinfo.Resolution_Date_2_2}}/{{quote.applicantinfo.Resolution_year_2}}
Additional Information #3

{{quote.applicantinfo.from_date_1_month}}/{{quote.applicantinfo.from_date_1_day_2}}/{{quote.applicantinfo.from_date_1_year_2}}
{{quote.applicantinfo.Explanation_1}}
{{quote.applicantinfo.Resolution_1}}
{{quote.applicantinfo.resolution_date_1_month}}/{{quote.applicantinfo.resolution_date_1_day_2}}/{{quote.applicantinfo.resolution_date_1_year_2}}
{{quote.applicantinfo.PolicyInception_month}}/{{quote.applicantinfo.PolicyInception_day}}/{{quote.applicantinfo.PolicyInception_year}}
{{quote.applicantinfo.TaxID}}
{{quote.applicantinfo.is_ForHire}}
{{quote.applicantinfo.is_statefiling}}
{{quote.applicantinfo.CertificateNumber}}
{{quote.applicantinfo.is_ICC}}
{{quote.applicantinfo.MCNumber}}
{{quote.applicantinfo.is_GL}}



Policy Coverage    Edit

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{{quote.policyCoverage.no_of_employees}}
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{{quote.policyCoverage.if_any_basis}}
{{quote.policyCoverage.cost_of_hire}}

{{quote.policyCoverage.PIP}}
{{quote.policyCoverage.pip_limit}}
{{quote.policyCoverage.MedicalPayments}}
{{quote.policyCoverage.UMUIMBI}}

{{quote.policyCoverage.UMUIMPD}}
{{quote.policyCoverage.is_InTowOnHook}}
{{quote.policyCoverage.limit}}
{{quote.policyCoverage.deductible}}

Driver Information    Edit

{{quote.driver_info.morethansix}}
{{ driver_file.file_name }}

Driver Name Date of Birth State License No MVR violation Years of experience Marital Status Gender CDL or Chauffer’s License Date of Hire #Violations #Accidents Details
{{ driver_info.name }} {{ driver_info.dob_month }}/{{ driver_info.dob_day }}/{{ driver_info.dob_year }} {{ driver_info.state}} {{ driver_info.licno }} {{ driver_info.mvr_violation }} {{ driver_info.years_exp }} {{ driver_info.married }} {{ driver_info.gender }} {{ driver_info.IsCDL}} {{ driver_info.doh_month }}/{{ driver_info.doh_day }}/{{ driver_info.doh_year }} {{ driver_info.violations }} {{ driver_info.accidents }} {{ driver_info.details }}

No Driver Info added

Vehicle Information    Edit

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{{ vehicle_file.file_name }}
{{quote.vehicleinfo.comp_deductible}}
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{{quote.vehicleinfo.personal_use}}
{{quote.vehicleinfo.percent_use}}
{{quote.vehicleinfo.desc_use}}

VIN Model Radius Stated Amt. Garage City Garage State Additional Interest Name Additional Interest Address Additional Interest Additional Interest State Additional Interest Zip Code Additional Interest Type GVW Comprehensive Deductible Collision Deductible
{{ vehicle.vehicle_no }} {{ vehicle.model}} {{ vehicle.radius }} {{ vehicle.stated_amt }} {{ vehicle.garage_city }} {{ vehicle.garage_state }} {{ vehicle.loss_payee_name }} {{ vehicle.loss_payee_mail_address }} {{ vehicle.loss_payee_city }} {{ vehicle.loss_payee_state}} {{ vehicle.loss_payee_zip }} {{ vehicle.add_interest_type }} {{ vehicle.GVW }} {{ vehicle.comp_deductible }} {{ vehicle.coll_deductible }}

No vehicles added

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Prior Insurance Information    Edit

{{quote.has_prior_2}}
{{quote.prior_cancel_details_2}}

Policy No. Valid From Valid to Insurance Company No. of Years Insured Under Business Name Premium Coverage Type Bodily Injury Property Damage Collision Other Damage Cargo
{{ priorinfo.policy_no_2}} {{ priorinfo.from_date_month_2 }} / {{ priorinfo.from_date_day_2 }} / {{ priorinfo.from_date_year_2}} {{ priorinfo.to_date_month_2 }} / {{ priorinfo.to_date_day_2 }} / {{ priorinfo.to_date_year_2}} {{ priorinfo.company_2 }} {{ priorinfo.No_of_Years_Insured_Under_Business_Name }} {{ priorinfo.Premium }} Auto Liability: {{ priorinfo.alSelected_2 }} ,General Liability: {{ priorinfo.glSelected_2 }} ,Property: {{ priorinfo.pSelected }} ,Other: {{ priorinfo.OSelected }} {{ priorinfo.bodily_injury_2 }} {{ priorinfo.property_damage_2 }} {{ priorinfo.collision_2 }} {{ priorinfo.other_damage_2 }} {{ priorinfo.cargo_2 }}

{{ quote.priorinfo.attachloss}}   {{ prior_file.file_name }}
{{quote.priorinfo.claimyears}}
{{quote.priorinfo.totalloss}}
Date of occurrence include driver involved and if bodily injury was involved Date of claim Amount reserved Claim open Amount paid
{{ quote.priorinfo.from_Date_of_occurrence_month }}/{{quote.priorinfo.from_Date_of_occurrence}}/{{quote.priorinfo.from_Date_of_occurrence_year}} {{ quote.priorinfo.occurance_claim_3 }} {{ quote.priorinfo.from_Date_of_claim_month_3 }}/{{quote.priorinfo.from_Date_of_claim_day_2_3}}/{{quote.priorinfo.from_Date_of_claim_year_3}} {{ quote.priorinfo.Amount_reserved_3 }} {{ quote.priorinfo.Claim_open_3 }} {{ quote.priorinfo.Amount_paid_3 }}
{{ quote.priorinfo.from_Date_of_occurrence_1_month }}/{{quote.priorinfo.from_Date_of_occurrence_1}}/{{quote.priorinfo.from_Date_of_occurrence_1_year}} {{ quote.priorinfo.occurance_claim_2 }} {{ quote.priorinfo.from_Date_of_claim_month_2 }}/{{quote.priorinfo.from_Date_of_claim_day_2_2}}/{{quote.priorinfo.from_Date_of_claim_year_2}} {{ quote.priorinfo.Amount_reserved_2 }} {{ quote.priorinfo.Claim_open_2 }} {{ quote.priorinfo.Amount_paid_2 }}
{{ quote.priorinfo.from_Date_of_occurrence_2_month }}/{{quote.priorinfo.from_Date_of_occurrence_2}}/{{quote.priorinfo.from_Date_of_occurrence_2_year}} {{ quote.priorinfo.occurance_claim_1 }} {{ quote.priorinfo.from_Date_of_claim_month_1 }}/{{quote.priorinfo.from_Date_of_claim_day_2_1}}/{{quote.priorinfo.from_Date_of_claim_year_1}} {{ quote.priorinfo.Amount_reserved_1 }} {{ quote.priorinfo.Claim_open_1 }} {{ quote.priorinfo.Amount_paid_1 }}
{{ quote.priorinfo.from_Date_of_occurrence_3_month }}/{{quote.priorinfo.from_Date_of_occurrence_3}}/{{quote.priorinfo.from_Date_of_occurrence_3_year}} {{ quote.priorinfo.occurance_claim }} {{ quote.priorinfo.from_Date_of_claim_month }}/{{quote.priorinfo.from_Date_of_claim_day}}/{{quote.priorinfo.from_Date_of_claim_year}} {{ quote.priorinfo.Amount_reserved }} {{ quote.priorinfo.Claim_open }} {{ quote.priorinfo.Amount_paid }}

No Prior Insurance Info added

Other Info    Edit

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If all of the above the information are correct, then kindly submit the form

I authorize W. E. Love & Associates and/or the producing broker to obtain proper cop(ies) of Motor Vehicle Report(s) and Insurance Scoring information for insurance underwriting purposes for all drivers listed and/or any drivers who will operate equipment covered under any prospective insurance policy for which this application relates. All drivers have or will authorize me to consent the same. I certify that all application information is true and agree that any misrepresentation by me will constitute reason for the company to void or cancel any policy issued on the basis of the application, and will hold the company harmless for the action taken.

I have read and agree to the Terms & Conditions.