Old - Commercial Auto Smart PDF

Completed by

Enter Acc. Manager / Producer

Agency Name

Enter the agency name, FYI this does not have an affect on automatic routing

Today's Date

Date

How did you hear about us

Completed by

Enter Acc. Manager / Producer

Agency Info:

Enter the Agency Name (DBA)

Enter the Agency Address

Rows	Address
Street
City
State
Zip

Enter the Agency Contact Name

Enter the Agency Phone Number

Agency Street Address

Enter agency prefix

Agency City Address

Enter agency prefix

Agency State Address

Enter agency prefix

Agency Zip Address

Enter agency prefix

Enter the Agency Fax Number

Enter the Agency E-mail

Client Info:

Is the Insured a legal entity such as a LLC or Corporation or are they Individual people/sole proprietor

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the Business entity. This must match 100% exactly as it appears on the policy

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

How many named insured will there be in the policy, therefore showing on the COL. (This must match the Policy)

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the 1st Named Insured

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

What is the name of the 2nd Named Insured

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

What is the name of the 3rd Named Insured

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

Does the named insured use a DBA

Note: This DBA would be how the business is advertised to the public unless they use the entity name only

What is the name of the DBA.

IMPORTANT: Make sure to enter the DBA name as it appears on all publications

mapping-DBA name

Will the DBA need to appear on COI

Note: This DBA would be how the business is advertised to the public unless they use the entity name only

Named Insured Address

Rows	Address
Street
City
State
Zip

Insured Street

Insured City

Insured State

Insured Zip

Commercial General Liability:

Does the client have Commercial General Liability with our agency

Who was Coverage placed with for this CGL policy

mapping- A letter on CGL

What's the name of the Ins. Carrier providing coverage on CGL policy

What's the name of the Writing Co for Assurant Flood on this CGL policy

What's the name of the Writing Co for American Modern on this CGL policy

What's the name of the Writing Co for BHHC on this CGL policy

What's the name of the Writing Co for CA Fair Plan on this CGL policy

What's the name of the Writing Co for Guard Ins. on this CGL policy

What's the name of the Writing Co for Hartford on this CGL policy

What's the name of the Writing Co for ICAT on this CGL policy

What's the name of the Writing Co for Infinity on this CGL policy

What's the name of the Writing Co for Mercury on this CGL policy

What's the name of the Writing Co for Nationwide on this CGL policy

What's the name of the Writing Co for Neptune Flood on this CGL policy

What's the name of the Writing Co for Progressive on this CGL policy

What's the name of the Writing Co for Stillwater on this CGL policy

What's the name of the Writing Co for Swyfft on this CGL policy

What's the name of the MGA providing coverage on CGL policy

What's the name of the Writing Co for 123ocp on this CGL policy

What's the name of the Writing Co for 5 Star Specialty on this CGL policy

What's the name of the Writing Co for Abram Interstate on this CGL policy

What's the name of the Writing Co for All Risks.com on this CGL policy

What's the name of the Writing Co for A&M on this CGL policy

What's the name of the Writing Co for ATM Ins. on this CGL policy

What's the name of the Writing Co for BTIS on this CGL policy

What's the name of the Writing Co for Bass Under. on this CGL policy

What's the name of the Writing Co for Burns & Wilcox on this CGL policy

What's the name of the Writing Co for Business Risk Partners on this CGL

What's the Writing Co for CatCoverage (NCIP) on this CGL policy

What's the Writing Co for CTC Ins. Marketing on this CGL policy

What's the name of the Writing Co for CannGen Ins Ser. on this CGL policyType a question

What's the name of the Writing Co for CK Specialty on this CGL policy

What's the name of the Writing Co for Cowbell Cyber on this CGL policy

What's the name of the Writing Co for Evolution Ins. Brokers on this CGL

What's the name of the Writing Co for Fortuna General Ins. on this CGL

What's the name of the Writing Co for Gateway Specialty.com on this CGL

What's the name of the Writing Co for Gorst & Compass on this CGL policy

What's the name of the Writing Co for Hull & Company on this CGL policy

What's the name of the Writing Co for JE Brown on this CGL policy

What's the name of the Writing Co for King Ins. on this CGL policy

What's the name of the Writing Co for K&K Ins. on this CGL policy

What's the name of the Writing Co for Markel Ins. on this CGL policy

What's the name of the Writing Co for Monarch Ins. on this CGL policy

What's the name of the Writing Co for Oak River Ins.Co. on this CGL policy

What's the name of the Writing Co for Presidio Ex. on this CGL policy

What's the name of the Writing Co for Proper Ins. Ser. on this CGL policy

What's the name of the Writing Co for RIC General Ins. on this CGL policy

What's the name of the Writing Co for R.E. Chaix & As. on this CGL policy

What's the name of the Writing Co for RPS on this CGL policy

What's the name of the Writing Co for RT Specialty on this CGL policy

What's the name of the Writing Co for Scottish Amer. on this CGL policy

What's the name of the Writing Co for Sierra Specialty on this CGL policy

What's the name of the Writing Co for SIS Wholesale In. on this CGL policy

What's the Writing Co for Socius Ins. Serv. Inc. on this CGL policy

What's the name of the Writing Co for Superior Access on this CGL policy

What's the name of the Writing Co for SureTec Ins. on this CGL policy

What's the name of the Writing Co for Tennant Risk Ser. on this CGL policy

What's the name of the Writing Co for Vacant Express on this CGL policy

What's the Writing Co for Worldwide Facilities LLC on this CGL policy

What's the name of the Writing Co for WSS on this CGL policy

What's the name of the Writing Co for US Assure.com on this CGL policy

What's the Writing Co for Vacant Express.com on this CGL policy

What is the carrier's NAIC number code

What is the Policy Number

What type of CGL policy is this

CGL Select

Claims-Made

Occurrence

Is there a waiver of Subrogation listed on this policy

map-Waiver of Subrogation

Will the certificate holder be also an additional insured for this CGL

map-addtl insured

How will the general aggregate limit apply

Please describe how limit will be applied

Answer will be under Gen'l aggregate limit applies per: other option

What is the effective date of the Policy

Date

What is the expiration date of the Policy

Date

Per Policy

Per Project

Per Location

Other

For Edit Submission

Date (for mapping FID-00)

Date

How did you hear about us?

Referred by:

If known otherwise type Unknown

Notes:

Application Information:

Legal Entity Type

Legal Entity Name

What is the DBA (Doing Business As)

What is the name of the DBA

When did the Business originally start

When did the business first open

What Date was this Entity established

Example- Date Incorporated or Date became LLC

Federal Employment ID (Tax ID Number)

What is the website for the business

What is the Social Media Page

How can we find the business in Facebook or other social media platform? Enter NONE if they don't have any.

Applicant's Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Copy to Physical Location Address

X 1Insured Street

X 1Insured City

X 1Insured State

X 1Insured Zip

Enter a Co-Owner/Co-Applicant

Prefix

Gender

Education

First Name

DOB

Type of Degree

Example: Science or Engineering Degree

Industry

Marital Status

Last Name

Suffix

Occupation

Relationship to Applicant

General Policy Information

Prior Carrier

Number of Drivers

Driver #1

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #2

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #3

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #4

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #5

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #6

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Driver #7

First Name

Last Name

Rated Driver

Relationship

Gender

Marital Status

DOB

DL#

DL State

Employment Status

Occupation Industry

Occupation Title

Student Type

Good Student Discount

Must be 12 units or more

Type of Degree

Example: Science or Engineering Degree

Job Status

Name of Employer

Commute Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commute (Days per Week)

Average days per week if varied

Car Pool (Days per Week)

If car pool with friend/ co-worker?

Company car provided?

If Company Car used for commute?

Number of Vehicles

Vehicle #1

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

Vehicle #2

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

Vehicle #3

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

Vehicle #4

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Addreess

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

Vehicle #5

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

Vehicle #6

VIN#

Year

Make

Model

Sub-Model

Cost New Value

Vehicle Use

Vehicle Use

Ownership Type

Car Pool

Rating Info

Current Odometer

Was the car new?

Alternate Garaging Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Coverage

Comprehensive

Collision

Towing/Road Side Assistance

Car Rental/Transportation Expense

Stated Amount

Loan/Lease Coverage

Waiver Collision Damage

General Policy Coverage

Bodily Injury

Bodily Injury Other Limit

Property Damage

Uninsured / Under Insured Motorist

Medical Payments

Attachments: (Optional)

Notes:

Request for Commercial Auto Insurance

Company Use Only : Do not complete below this line

EZLynx Data Entry