Commercial Vehicle Supplement

Date:

Effective Date:

Policy Number:

Name of Insured:

Broker:

Name of Principal:

Years in business:

Business of Insured:

Described Vehicle

Auto 1

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 2

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 3

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 4

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 5

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 6

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 7

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 8

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 9

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Auto 10

Year:

Make/Model:

VIN:

List Price New:

Type: i.e. PU/Van/Dump, etc.:

Attached Equipment:

Automobile Use

Auto 1

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 2

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 3

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 4

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 5

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 6

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 7

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 8

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 9

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Auto 10

Normal Radius of Operation:

Maximum Radius of Operations:

Annual Mileage:

Vehicle Use or Type of Goods Carried:

Are Goods Carried Owned Goods or For Others:

If Delivery Vehicle -- Retail or Wholesale:

Is Vehicle used for snow plowing or snow removal?:

Please provide details of snow removal operations -- where, for whom, gross receipts, etc.:

Any USA Exposure?:

Driver Information

Driver 4

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 3

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 2

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 5

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 7

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 9

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 8

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 1

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 6

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Driver 10

Name:

Date of Birth:

License Number:

Province:

Class of License:

Year Hired:

Vehicle(s) Driven:

Claims Information

Claim 2

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Claim 3

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Claim 5

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Claim 6

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Claim 1

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Claim 4

Date:

Coverage:

Amount Paid:

Vehicle:

Driver:

Description:

Additional Information: