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*

	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*

	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:

EDE

Request for Commercial Auto Insurance

Company Use Only : Do not complete below this line

EZLynx Data Entry