R2017-116 Liability Insurance Coverage for Transit System

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COVERAGE INFORMATION Limits of Liability(CSL) Other Auto Liability [_1 S1,500,000 Z$5,000.,000 Personal Injury Protection(PIP)(No Fault) ❑Reject 0 Basic Limits Added PIP(No Fault) Fj Reject F] Basic Limits Uninsured Motorists(UM) ❑ Reject Z Basic Limits Underinsured Motorists*(UIM) (when not included in U,11) El Reject Z Basic Limits Hired Auto Liability ❑S 1,500,000 Z$5,000,000 Employer's Non-Ownership Liability El $1,500,000 ®$5,000,000 General Liability Other(Specify): 0$1,000,000 Z S5,000,000 - S Physical Damage Deductibles Specified Perils—Stated Amount-ACV(Actual Cash Value) R$1,000 0$2,500 R$5,000 ❑$10,000 Collision—Stated Amount-ACV(Actual Cash Value) El $1,000 R$2,500 R$5,000 E] $I0,000 An additional premium will apply when UIA-f coverage is not included within the U,41 coverage. UL44 coverage can be rejected. PRODUCER INFORMATION Producer: Greg Nussbaum Phone No: 309-275-4026 Address: PO Box 14 License No.: 321790 City: Forsyth County: Macon State: -IL zip: 62535 Are you the incumbent producer? Z Yes [I No Is this business sub-produced? R Yes 0 No If Yes, Sub-Producer Name: Telephone: Fax: E-Mail Address: PLEASE READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN THIS APPLICATION. I hereby apply for the insurance indicated above and represent that: I) I have read this application. 2) The limits and coverages requested were selected by me. 3) All statements herein are true and accurate, to the best of my knowledge, and no material facts have been suppressed or misstated. I understand that misrepresentation or omission of material'facts will be cause for cancellation and may void coverage. 4) By signing this application, I authorize the insurer to obtain copies of motor vehicle reports for underwriting the indicated insurance,as well as the right to examine or inspect files, records,documents and equipment in order to determine the accuracy of the information stated herein. The completion of this application creates no express or implied obligation on the part of the insurer or its manager to offer a quotation or provide insurance as requested in this application and survey. If the insurance is provided, the policy will only cover the vehicles listed on the attached schedule for the coverages agreed. You must immediately notify the insurer in writing if there is any change in your equipment or operations,and all accidents must be reported promptly regardless of severity or fault. Lancer BLj,&ong Application(09/13) Page 8 of 10