Form M 4493B Il – Fill Out and Use This PDF

Drive-Away Application

COLUMBIA INSURANCE COMPANY

NATIONAL FIRE & MARINE INSURANCE COMPANY

NATIONAL INDEMNITY COMPANY

NATIONAL INDEMNITY COMPANY OF MID-AMERICA

NATIONAL INDEMNITY COMPANY OF THE SOUTH

NATIONAL LIABILITY & FIRE INSURANCE COMPANY

Policy Term From:

To

1.

Name (and "dba")

G Individual/Proprietorship

G Partnership G Corporation

G Other

Business Phone Number

2.

Mailing Address

City

State

Zip

3.

Premises Address

City

State

Zip

4.

Person to contact for inspection (name and phone number)

5.

Have you ever had insurance with one of the companies listed at the top of this page? G Yes G No

If yes, Policy Number(s)

Effective Date(s)

DESCRIPTION OF OPERATIONS

6.

Describe business

Years experience

New Venture? G Yes G No

7.

Is this your primary business? G Yes G No

If no, explain

8.

Have you ever filed for Bankruptcy? G Yes G No If yes, when

Explain

9.

Gross receipts last year

Estimate for coming year

Business for sale? G Yes

G No

10.

Do you operate in more than one state? G Yes

G No

If yes, list states

11.

Do you operate over a regular route? G Yes

G No

If yes, show towns operated between:

LIABILITY COVERAGE — Complete for desired coverages by indicating limits of insurance.

APPLICABLE PERSONAL INJURY PROTECTION, UNINSURED AND/OR UNDERINSURED

MOTORISTS INSURANCE SELECTION/REJECTION PAGE IS REQUIRED TO BE COMPLETED AND

SIGNED BY THE NAMED INSURED WITH THE SUBMISSION OF THIS APPLICATION.

DRIVER INFORMATION — If additional space is needed, attach separate listing.

				Driver's Licenses			Experience
	Driver's Name	Date of Birth			Class/Type	Years	Type of Unit
			State	Number			(Bus, Van,	No. of
						Licensed (in
					(i.e. CDL)	Class/Type)	Truck, Tractor,	Years
							etc.)

1.

2.

3.

4.

5.

DRIVER INFORMATION (Continued) — If additional space is needed, attach separate listing.

No. Years			Accidents and Minor Moving Traffic				Major Convictions
							(DWI/DUI, Hit & Run, Manslaughter, Reckless,			Employee (E)
Previous			Violations in Past 5 Years				Driving While Suspended/ Revoked, Speed
										Ind. Cont. (IC)
Commercial	Date of Hire						Contest, other felony)
										Owner/Op. (O/O)
Driving
		No. of		No. of						Franchisee (F)
Experience			Date(s)			Date(s)	Describe Conviction		Date(s)
		Accidents		Violations
1.
2.
3.
4.
5.

PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.

M-4493b IL (06/2007)

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ILLINOIS

UNINSURED MOTORIST & UNDERINSURED MOTORIST

ELECTION FORM

Uninsured Motorists Coverage provides you protection when you are legally entitled to recover damages for bodily injury or death, caused by the owner of an uninsured auto.

Underinsured Motorists Coverage provides you protection when you are legally entitled to recover damages for bodily injury or death, caused by the owner of an auto which was insured at the time of loss, but whose limits of Bodily Injury Liability Coverage are less than you are legally entitled to recover, as the injured party.

These additional Coverages are required to be part of your auto policy at limits equal to the minimum limits required by the State Financial Responsibility Law. They are, however, available to you at any limits up to the Bodily Injury Liability Coverage limits of your policy, at additional premium.

To be certain that your policy is issued correctly, please indicate your choice concerning the limit desired for this additional coverage. (“x” indicates your choice)

UNINSURED/UNDERINSURED MOTORISTS BODILY INJURY COVERAGE

Elected with 20/40 limits of liability (minimum coverage required by law)

Elected with a combined single limit of $40,000 (minimum coverage required by law)

Elected with combined single limit of liability of $ (May not exceed bodily injury limit)

Elected with split limits of liability of $	/ $
(May not exceed bodily injury limits)

In the event none of these options are selected, Uninsured/Underinsured Motorists Bodily Injury coverage will be issued with the same limits of liability as Bodily Injury coverage.

Signature of Named Insured

Date

Signature of Named Insured

Date

Until you advise us otherwise in writing, your choice as indicated above, will continue regardless of any addition or change in Auto coverage on your current policy or addition of any scheduled Autos and will be carried forward on all future renewal policies without additional notice.

SIGNATURE IS ALSO REQUIRED ON LAST PAGE OF APPLICATION

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MUST BE SIGNED BY THE APPLICANT PERSONALLY

No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may not accept any funds for the Company, and may not modify or interpret the terms of the policy.

The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false, the Company may rescind any policy or subsequent renewal it may issue.

If any jurisdiction in which the Applicant intends to operate or the FHWA requires a special endorsement to be attached to the policy which increases Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that endorsement.

The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect.

The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation.

The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has personally signed below (or if Applicant is a Corporation a corporate officer has signed below).

Will premium be financed? G Yes G No If yes, with whom?

WitnessApplicant's SignatureDate

TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE

Is this direct business to your office?

If not, explain:

Is this new business to your office?

If not, how long have you had the account?

How long have you known applicant?

REQUEST TO COMPANY GENERAL AGENT:

G Please quote

G Please bind at earliest possible date and issue policy

G Please issue policy effective

Coverage was bound by

(Time and Date Bound by General Agent)

(Name of Person in Company General Agency's Office Binding Coverage)

Applicant's Representative's Name and Address

Phone No.

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