Excess Commercial Auto Liability

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- Agency Name
- Address
- Contact Name
- Agency Account Nbr.
If you do not have an account with FTP complete and forward our
New Brokerage Account Questionaire

Select State in which the Risk is located:

- Applicant's Name
- Address
- Terminal Locations

Merchandise or Commodity Hauled:

Radius of Operation:

Losses past three years:

Hired or Non Owned Vehicle Exposure: YES NO
If yes, advise number of employees.

Excess Policy Term From: To :

Primary Carrier: Policy #

Primary Premium : BI $ : PD

Primary Policy Terms From: To :

Assigned Risk?

COVERAGE: PRIMARY X/S REQUIRED TOTAL LIMITS
B.I. PERSON OCCURRENCE $ $ $
P.D. OCCURRENCE $ $ $
SINGLE LIMIT OCCURRENCE $ $ $
* If difference between CSL & Split Limits required, show primary Split Limit and Single Limit under CSL.

SCHEDULE OF VEHICLES:

Year Make Body Type Serial # Gross Vehicle Weight
1.
2.
3.
4.

SCHEDULE OF DRIVERS:

Name Date of Birth License #
1.
2.
3.
4.

If Primary is Garage Liability also advise:
PAYROLL
RECEIPTS
AGGREGATE LIMIT?


The business of the applicant is:


Enter any Additional Information Here:


Thank You for submitting this risk.
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