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General Liability Supplement

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					                                                                    Insurance Application
                                              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.

Applicant Name:
Agency Name:
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
     Impairment Coverage.


 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
       Medical Expense
       (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
                                             OCCURRENCE
                                                                                                                     OPEN         CLOSED




     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

				
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