SAFECO INSURANCE CO.

Owner / Operator Dump Truck Application

Please answer all questions. If a question does not apply, indicate ‘not applicable’.

Agency Name :

Agency Number :

Agent Name :

Agency Phone : (000) 000-0000

Agency Email :

Applicant's Name :

Effective Date : (mm/dd/yyyy)

DBA Name :

Applicant Mailing Address :

City :

State :

Zip Code :

Applicant Phone : (000) 000-0000

Common Carrier (general public) : Yes No

Contract Carrier (specific customers with contract) : Yes No

Number Of Contracts :

Names of companies contracted with :

Delivers their own product :Yes No

Description of Operations :
Individual Corporation Partnership Joint Venture Other

A. UNDERWRITING INFORMATION

Years In Business:

Provide details of work performed:

Haul material other than sand, gravel, rock, topsoil or bark?:YesNo
Explain Material Hauled:

Radius Of Operation:

Truck equipped with back up alarm? YesNo

Are there any other drivers?:YesNo
Explain if yes :

Transport hazardous materials?:YesNo
Explain if yes :

Is ICC, PUC or other filing required?:YesNo
Explain if yes :

Other than encumbrances, is vehicle not solely owned by and registered to applicant?:YesNo
Explain if yes:

Is vehicle customized, altered or have any special equipment?:YesNo
Explain if yes:

Does the insured have standards for drivers that require no more than two moving violations, and no major violations, as a minimum standard?:YesNo
Explain if no:

Do over 50% of the employees use their autos in the business?:YesNo
Explain if yes:

Are vehicles used by family members?:YesNo

B. VEHICLE INFORMATION

Enable Javascript to be able to enter multiple vehiclesCost newYearMakeModelBody TypeVINGVW# of Contract ClientsStreet: City:

State: Zip where garagedSYMBOL

C. DRIVER INFORMATION

Enable Javascript to be able to enter multiple driversDriver NameDrivers License NumberSexDate of BirthState Licensed

D. LIMITS

Liability: Med Pay : UM :

PIP options Without Workers Compensation: YesNo UM Stacked Coverage: YesNo

Comprehensive Deductible: Collision Deductible:

Hired & Non-owned?: YesNo

If yes, please provide the following:

Number of Employees:

Annual Hired Employee Expenditure:

Comprehensive Deductible:

Collision Deductible:

E. HISTORY

Prior Insurance Carrier:

During the past three years, has any company canceled, declined or refused similiar insurance to the Applicant?:
YesNo

If Yes, please explain:

This application does not bind the Applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, OH, OK, OR or VT; In DC, LA, ME and VA insurance benefits may also be denied)

Enter a valid e-mail address to receive a copy of the completed form in PDF format. This copy can be signed and faxed back to us once coverage has been bound.