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STRATFORD INSURANCE COMPANY WEST

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					           STRATFORD INSURANCE COMPANY                                    WESTERN WORLD INSURANCE COMPANY
                                 PUBLIC AUTO INSURANCE APPLICATION - GEORGIA
A.   GENERAL
     Applicant's Name:                                                                       Phone #:
     Contact Person:                                                             Proposed Effective Date:
     Address:                                                                                 Expiration Date:
     Garaging Location(s) if different:
     Is your business? 1.         Individual       Partnership            Corporation                   Other
                          2.      Seasonal         Non-Profit             Government Funded
     Nature Of Business:                                                                                 Years In Business:
     Years Operating in Your Current Name:                    Web Site:
     Have you owned a similar business or had any change in ownership, management or name of your current business
     during the past 5 years?     Yes       No
     If yes, please explain:
     Is your business a subsidiary of another entity or does your business have any subsidiaries?                Yes        No
     If yes, provide details:

B.   COVERAGES REQUESTED (Provide limit where applicable.)
        Liability                              Medical Payments                                 Physical Damage – See Section G.
           Scheduled Autos                     Uninsured/Underinsured                               Specified Causes/Collision, or
           Hired Autos                         Motorists – See Section H.                           Comprehensive/Collision
           Non-Owned Autos                                                                      Other

C.   OPERATIONS
1.   Check each of the services you provide:
         Taxi                             Special Occasion Limousine             Kid Cab                          Jeep Tour
         School Bus/Van                   Airport Limousine                      Employee Van Pool                Other
         Church Bus/Van                   Executive Limousine                    Guide/Outfitter
         Casino Bus/Van                   Daycare Bus/Van                        Sightseeing
         Social Service Agency (Please describe):
         Shuttle Service (Between what destinations?)
2.   Do you transport passengers for a fare?         Yes           No
3.   Do you regularly transport elderly passengers?           Yes         No
4.   Do you regularly transport passengers to medical facilities?          Yes          No
5.   Do you regularly transport physically disabled passengers?            Yes       No
6.   Are any vehicles equipped with wheelchair lifts?           Yes       No
7.   What is the average number of hours per day each vehicle is operated?                    Percent of night driving?
8.   Is there any personal use of vehicles?        Yes        No
     If yes, please explain:
9.   Are drivers allowed to take vehicles home when not in use?            Yes          No
     If yes, are there any relatives under 23 years of age residing in the driver’s household?           Yes           No
     If yes, please explain:




                                                         Page 1 of 4                                                   ST GAPA (01/09)
10. Maximum radius of operations:                           Miles
11. Territory (Largest Cities/Towns into, near or through which vehicles are operated.)
    a.                         b.                                 c.                               d.
12. Do you travel to Michigan?         Yes       No      If yes, how many days per month?
13. Do you travel to Ontario, Canada?              Yes            No
14. Do you lease, hire, rent, or borrow any vehicles from others?                  Yes      No
     If yes, what is your cost to lease, hire or rent vehicles?     $
15. Do you use independent contractors as drivers?            Yes             No
     If yes, will their vehicles be scheduled on your policy?           Yes          No
16. Filings:
     FMCSA MC #                               Base State:                                  State Filings:

D.   DRIVERS (Add additional sheet(s) if necessary.)
                                                                                                     Original CDL *Accidents or
                                                                                                     Date (if driving Violations in
                                                                                    Date of           unit carrying the Last Three
 Driver’s Name (As shown on        Driver’s License No. and State       Date of       Hire    Years        15+           Years
       Driver’s License)                  Where Licensed                 Birth      (Mo/Yr) Licensed passengers)       (Yes/No)




*Please provide details for any accidents or violations.




Are your employees covered by Workers’ Compensation?                               Yes     No
Do you agree to promptly report all new drivers?                                   Yes     No
Are all your drivers your employees?                                               Yes     No


                                                         Page 2 of 4                                               ST GAPA (01/09)
E.    PRIOR INSURANCE CARRIERS AND LOSS EXPERIENCE (Add additional sheet(s) if necessary.)
                                                              Aver-
                                                               age
                                                              No. of                                                Cancelled or Non-
                Insurance                                     Power            *Total Liability   *Total Physical      Renewed?
Policy Dates      Carrier       Policy #       Premium        Units               Claims          Damage Claims        (Reason)
                                               $                           #       $              #    $
                                               $                           #       $              #    $
                                               $                           #       $              #    $
                                               $                           #       $              #    $
                                               $                           #       $              #    $
*This section should be completed unless you have attached loss runs for all years. Please describe any loss over $25,000:




Any drivers involved in more than one claim?           Yes            No           Who?
If yes, is that driver currently employed?             Yes            No


F. VEHICLE INFORMATION (Add additional sheet, if necessary)                       G. PHYSICAL DAMAGE
                                                                                                    Amount of
                                                                                                    Insurance
                      Body Type                                                    Month/             (Must
                        (Van,                                                       Year     Cost     equal                         *Loss
         Model        Limo, Bus,                                  Seating             of       at    present             Deduct-   Payee
       Year/Make         etc.)             Vehicle ID No.         Capacity        Purchase Purchase   value)              ible      (Y/N)
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
10.
11.
*Please list name and address of loss payee by vehicle:




 Identify any vehicles equipped with wheelchair lifts:

 Do you have a regular vehicle inspection and preventive maintenance program?                    Yes                No
 If yes, please describe:
 Do you own any vehicles which will not be covered under this policy?                Yes         No
 If yes, please list all vehicles not covered and the insurance carrier covering those vehicles:



                                                            Page 3 of 4                                                  ST GAPA (01/09)
  H.    UNINSURED MOTORISTS (UM) COVERAGE
Georgia law requires that UM coverage is offered under all auto liability policies in the state. This coverage protects you
against bodily injury or property damage loss caused by an owner or operator of an uninsured vehicle, a hit-and-run vehicle,
or an underinsured vehicle. (A vehicle is underinsured when the liability coverage of the person responsible for your injuries
does not cover the loss up to the limit you selected.) UM coverage must be provided at the minimum limits required by the
State Financial Responsibility Law, unless you select higher limits or reject UM coverage in its entirety.
       I REJECT UM Coverage in its entirety. If you check this box, go directly to the signature line. Sign your name and
       enter date.
       I SELECT UM Coverage. If you check this box, please complete items A. and B. below:
       A. Select one of the following:
                I choose UM coverage at the minimum limits required by law.
                I choose UM coverage at limits shown below (not to exceed the policy's liability insurance limits):
           $                 Single Limit; OR
            $                  per person / $                         per accident / $                   property damage
       B.   Select one of the following:
                  I choose UM Coverage – Added On To At-Fault Liability Limits.
                  With this option, the entire UM Coverage limit you select is available in addition to any amounts payable by
                  the at-fault driver's liability policy. This coverage is provided at a higher premium.
                  I reject Added On To At-Fault Liability Limits and instead choose UM Coverage – Reduced By At-Fault
                  Liability Limits.
                  With this option, UM coverage will pay up to the difference between the at-fault driver's liability coverage
                  and the UM limit you select. This coverage is provided at a reduced premium.
I understand that any selection/rejection I make will apply regardless of any addition or change in coverage on my current
policy and will carry forward on all renewal policies unless I give written notice otherwise.

Applicant's Signature                                                      Date

  I.   UNINSURED MOTORISTS (UM) COVERAGE - NOTICE
If you have chosen to accept UM coverage and have any questions after reading this statement regarding UM coverage or the
amount of coverage you have selected, your agent or company representative will be able to assist you. You should have
chosen the amount of UM coverage you want based on this question: If I get hit by someone with little or no liability
insurance, how much protection do I need to cover the cost associated with car repair, medical bills, other expenses, and lost
wages? If the person who hits your automobile has no liability coverage or liability coverage equal to or less than the UM
amount you chose, your total automobile insurance recovery (from all companies involved) may not exceed the amount of UM
coverage you chose.
The purpose of this notice is informational. This notice does not change or replace the wording in your policy.

Applicant's Signature                                           Date

 J.  AGREEMENTS AND SIGNATURES
APPLICANT: I BELIEVE THE STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT. I UNDERSTAND THAT
THE INSURER WILL RELY ON THESE STATEMENTS IF A POLICY IS ISSUED. I AGREE TO PROMPTLY REPORT ALL
FULL TIME AND PART TIME DRIVERS. MY EMPLOYEES UNDERSTAND THAT MOTOR VEHICLE REPORTS WILL BE
ORDERED. ON THEIR BEHALF, I AUTHORIZE THE INSURER TO ORDER THESE REPORTS ON EACH DRIVER I
EMPLOY OR CONTRACT. THIS APPLICATION ALONE DOES NOT BIND COVERAGE. I UNDERSTAND THAT THIS
POLICY DOES NOT PROVIDE ANY COVERAGE IN ONTARIO, CANADA.

FRAUD WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR
MISLEADING INFORMATION IS GUILTY OF A CRIME.

Applicant's Signature                                           Producer’s Signature

Date                                                            Date




                                                      Page 4 of 4                                             ST GAPA (01/09)

				
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