Truckers General Liability Supplement
PLEASE NOTE: An ACORD 125 and 126 will be required if 1) Additional Insureds are requested, or 2) A liability deductible is being requested, or 3) Any
class codes other than 99793 are identified under Section B, or 4) Any exposures other than trucking are identified in the General Information section.
Policy Number: Effective Date:
SECTION A - GENERAL INFORMATION
1. Does Lincoln General write your primary auto coverage? Yes No
2. Is this business a subsidiary of another entity or do you have any subsidiaries? Yes No
If Yes, provide details:
3. List and describe any other business operations conducted and/or properties owned or rented.
4. List and describe any businesses or occupancies adjacent to yours (list those connected to you and those within 50’).
5. If you responded to question 4, has your business location ever incurred any fire or safety code violations?
Yes No If Yes, provide details and dates of correction:
6. Have you incurred any past claims or losses relating to sexual abuse or molestation allegations, Yes No
discrimination or negligent hiring? If Yes, provide details:
7. Are there animals on, or patrolling, your business location? If Yes, provide details: Yes No
8. Do you have any fuel storage and/or underground tanks at your business location? Yes No
If Yes, provide details regarding the type of fuels stored. Attach a certificate of insurance confirming Environmental
9. Do you have any hold harmless, warranties, trailer interchange and/or intermodal agreements in Yes No
place? If Yes, provide details:
10. Do you use leased employees and/or owner/operators? If Yes, provide details. If you have Yes No
owner/operators, complete Leased Owner/Operator Supplement.
11. Do you perform any repair operations on vehicles other than those you own? Yes No
If Yes, provide details:
SECTION B – SCHEDULE OF HAZARDS
Location(s) to be covered: Location 1: Loc 2:
Classification(s) to be covered:
Class Code 99793: TRUCK TERMINAL COVERAGE RATED AS TRUCKERS (This classification includes coverage
for Products and/or Completed Operations. Products-Completed Operations are subject to the General Aggregate Limit.)
Number of drivers: Non-Driver Payroll:
Class Code: Class Description: Exposure Basis: Exposure:
LGSUP 015 0706 Page 1 of 2 Lincoln General Insurance Company, York, PA
SECTION C – COVERAGE AND LIMITS SECTION
Coverage and limits: Coverage will be provided on an occurrence basis, subject to the limits selected below, and subject
to all terms and conditions of the policy:
To Select this limit ‘package’ To Select this limit ‘package’ To Select this limit ‘package’
check here check here check here
Each Occurrence: $500,000 $1,000,000 $1,000,000
Personal & Advertising Injury: $500,000 $1,000,000 $1,000,000
General Aggregate: $1,000,000 $1,000,000 $2,000,000
Products & Completed Included in Each Included in Each Included in Each
Operations Aggregate: Occurrence limit Occurrence limit Occurrence limit
Damage to rented premises
(each occurrence) $100,000 $100,000 $100,000
(any one person): $5,000 $5,000 $5,000
SECTION D – LOSS HISTORY
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURENCES THAT
MAY GIVE RISE TO CLAIMS FOR THE PRIOR 3 YEARS.
DA DATE OF CLAIM OR DESCRIPTION OF AMOUNT PAID AMOUNT CLAIM STATUS
OCCURENCE CLAIM OR RESERVED
SECTION E - REMARKS SECTION
Provide additional information in the space below. If you are explaining answers to particular questions, please
indicate the question numbers.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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, WHICK IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL
AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, and VA,
insurance benefits may also be denied)
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE
ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE CERTIFIES THAT
THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
SIGNATURE OF FIRST NAMED INSURED DATE AGENCY NAME
TITLE: (Owner, Partner, President, Etc.) ADDRESS
SIGNATURE OF Agent, Broker or Solicitor (PRODUCER) DATE LINCOLN AGENCY NUMBER
LGSUP 015 0706 Page 2 of 2 Lincoln General Insurance Company, York, PA