Transcription of AGENCY CUSTOMER ID: BUSINESS AUTO SECTION
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Example: bachelor of science
AGENCY CUSTOMER ID: BUSINESS AUTO SECTION
OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?* MARITAL STATUS / CIVIL UNION (if applicable)EFFECTIVE DATENAMED INSURED(S)POLICY NUMBERNAIC CODECARRIERAGENCYAGENCY CUSTOMER ID:The ACORD name and logo are registered marks of ACORDNAME OF OTHER OWNERVEH #NAME OF OTHER OWNERVEH #WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY ANDREGISTERED TO THE APPLICANT? / NEXPLAIN ALL "YES" RESPONSESGENERAL OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS ? (no explanation needed) THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION? ANY VEHICLES LEASED TO OTHERS?VEH #VEH #$COSTDESCRIPTION$ CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups) ICC (Interstate Commerce Commission), PUC (Public Utility Commission) OR OTHER FILINGS REQUIRED? (If "YES", attach ACORD 194) (no explanation needed) 1993-2015 ACORD CORPORATION. All rights to ACORD 125 ACORD 127 (2015/12)COVERAGES / LIMITSUSE ACORD 137 FOR YOUR STATE TO PROVIDE COVERAGES / LIMITS INFORMATIONACORD 163 attached for additional driversDRIVER INFORMATIONCITY, STATE AND ZIP CODEDOCUSE%VEH #USEHIREDATELICSTATESOCIAL SECURITY NUMBERDRIVERS LICENSE NUMBER/LICYEAREXPYRSDATE OF BIRTHSTAT* MARSEXNAME#DRIVERLIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY AUTO SECTIONDATE (MM/DD/YYYY)DESCRIPTION OF GARAGE / STORAGE LOCATIONS$MAXIMUM DOLLAR VALUE SUBJECT TO
the undersigned is an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application.
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