Commercial Insurance Underwriter
CIU Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

Food Delivery Application

Applicant's Name

Agency Name

Address

Agent

 

Address

Location

 

 

Email

Web Site Address

Phone

 

See Accord Application   INDIVIDUAL   CORP.   PART.   OTHER:
TYPE OF COVERAGE SOUGHT: REQUESTED EFFECTIVE DATE:
  Hired   Non-Owned   Owned
LIMIT OF LIABILITY Need a Quote:
  $100,000. CSL $500,000. CSL

$1,500,000. CSL

   Excess of driver's insurance policy.
  $300,000. CSL $1,000,000. CSL Excess of a primary policy held by this Applicant.
 

Primary Limit:

Primary Carrier:

 

OPERATION DELIVERS: Pizza Chinese Food Other:
       
Applicant is an: Independent    Franchise of:
Number of years in business:     Number of years experience:

 

Annual Delivery Receipts Last Year:: $ Prior Carrier:
Annual Delivery Receipts Coming Year: $ Limit:
Total Annual Receipts: $ Ded/SIR:
Total Number of Owned Vehicles: $ Premium:

 

# of Full Time Drivers: # of Part Time Drivers:
Number of Locations: One, Shown Above, OR # listed below:
 
Five (5) Years Loss History for Hired and Non-owned Auto:
Five (5) Years Loss History for Owned Autos:

 

DRIVER QUALIFICATIONS
What auto liability limits are the drivers required to maintain?
Do you have driver requirements: NO YES (ATTACH COPY)
Do you have a driver safety program: NO YES (ATTACH COPY)

 

APPLICANT AGREES TO THE FOLLOWING DRIVER CRITERIA:

  • Driver's MVR's are checked at least every six months and at initial hire to confirm eligibility under insurance policy.

  • Driver's auto liability insurance is checked at least every six months and at initial hire to confirm at least minimum financial responsibility limits are held and current.

  • All vehicles driven on behalf of the Insured meet the state's safety requirements.

  • Driver must be at least 18 & with a minimum 2 years U.S. driving experience.

  • Driver must have no more than two moving violations in 36 months and one at fault accident.

  • No major traffic citations or incidents.

I UNDERSTAND THAT I MAY ONLY EMPLOY A DRIVER THAT MEETS THE ABOVE DRIVER CRITERIA.

 

DATE:______________  SIGNATURE___________________________________________________ :APPLICANT

 

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.