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              BUSINESS AUTO LIABILITY & PHYSICAL DAMAGE        
                     
                     
                     
                     
                     
                             
      (Required Information marked with an *)              
                             
      GENERAL INFORMATION                
      * Insureds First Name:          
                               
      * Insureds Last Name:          
                               
        DBA Name:            
                               
      * Mailing Address:        
                               
      * Mailing Address 2:        
                               
      * City:              
                               
      * State:  
    		             
                               
      * Zip:                    
                               
      * County:              
                               
        Have you moved in the last 60 days:
    		         
                               
        Home Phone:              
                               
        Mobile Phone:              
                               
        Work Phone:              
                               
        E-Mail Option:
    		           
                               
        E-Mail Address:        
                               
        Federal ID # or Social Security #:        
                               
        In connection with this application for insurance, we may review your credit report or obtain or use a credit-based score based on the information contained in that credit report. We may use a third party in connection with the development of your credit score. We will also obtain your driving record and claims history information from consumer reporting agencies.        
               
               
               
               
               
        Insured's Consent:
    		       
                               
      * Entity:  
    		             
                               
      * Business Category:
    		       
                               
      * Business:          
        (Please describe in detail)        
                     
                               
      * Years in Business:  
    		           
                               
      * Bankruptcies or Liens:
    		             
                               
                               
      DRIVER INFORMATION                
      * Drivers:   Driver 1   Driver 2   Driver 3  
      * First Name:        
      * Last Name:        
      * Date of Birth:        
      * Gender:  
    		 
    		 
    		 
      * Marital Status:  
    		 
    		 
    		 
      * Driver Status:  
    		 
    		 
    		 
      * # Years US Experience:      
      * Driv. License Status:
    		 
    		 
    		 
      * CDL License:  
    		 
    		 
    		 
      * License State:        
      * Driv. License Number:      
                               
                               
      * Drivers:   Driver 4   Driver 5   Driver 6  
      * First Name:        
      * Last Name:        
      * Date of Birth:        
      * Gender:  
    		 
    		 
    		 
      * Marital Status:  
    		 
    		 
    		 
      * Driver Status:  
    		 
    		 
    		 
      * # Years US Experience:      
      * Driv. License Status:
    		 
    		 
    		 
      * CDL License:  
    		 
    		 
    		 
      * License State:        
      * Driv. License Number:      
                               
                               
      * Drivers:   Driver 7   Driver 8   Driver 9  
      * First Name:        
      * Last Name:        
      * Date of Birth:        
      * Gender:  
    		 
    		 
    		 
      * Marital Status:  
    		 
    		 
    		 
      * Driver Status:  
    		 
    		 
    		 
      * # Years US Experience:      
      * Driv. License Status:
    		 
    		 
    		 
      * CDL License:  
    		 
    		 
    		 
      * License State:        
      * Driv. License Number:      
                               
                             
      VEHICLE INFORMATION                
      * Vehicles:   Vehicle 1   Vehicle 2   Vehicle 3  
      * VIN #:          
      * Vehicle Category:  
    		 
    		 
    		 
      * Model Year:        
      * Make:          
      * Model:          
      * Primary Use:  
    		 
    		 
    		 
        Form "E" Filing:  
    		 
    		 
    		 
      * Current Vehicle Value:      
        Attached Equip. Value      
      * Anti Theft:  
    		 
    		 
    		 
        Airbags:  
    		 
    		 
    		 
        Passive Restraint:  
    		 
    		 
    		 
      * Garaging Zip Code:      
      * Business Radius:  
    		 
    		 
    		 
      * Average Jobsites/Day:
    		 
    		 
    		 
      * Gross Vehicle Weight:      
                               
                               
      * Vehicles:   Vehicle 4   Vehicle 5   Vehicle 6  
      * VIN #:          
      * Vehicle Category:  
    		 
    		 
    		 
      * Model Year:        
      * Make:          
      * Model:          
      * Primary Use:  
    		 
    		 
    		 
        Form "E" Filing:  
    		 
    		 
    		 
      * Current Vehicle Value:      
        Attached Equip. Value      
      * Anti Theft:  
    		 
    		 
    		 
        Airbags:  
    		 
    		 
    		 
        Passive Restraint:  
    		 
    		 
    		 
      * Garaging Zip Code:      
      * Business Radius:  
    		 
    		 
    		 
      * Average Jobsites/Day:
    		 
    		 
    		 
      * Gross Vehicle Weight:      
                               
                               
      * Vehicles:   Vehicle 7   Vehicle 8   Vehicle 9  
      * VIN #:          
      * Vehicle Category:  
    		 
    		 
    		 
      * Model Year:        
      * Make:          
      * Model:          
      * Primary Use:  
    		 
    		 
    		 
        Form "E" Filing:  
    		 
    		 
    		 
      * Current Vehicle Value:      
        Attached Equip. Value      
      * Anti Theft:  
    		 
    		 
    		 
        Airbags:  
    		 
    		 
    		 
        Passive Restraint:  
    		 
    		 
    		 
      * Garaging Zip Code:      
      * Business Radius:  
    		 
    		 
    		 
      * Average Jobsites/Day:
    		 
    		 
    		 
      * Gross Vehicle Weight:      
                               
                               
      PRIOR POLICY INFORMATION              
        Continuous Coverage:
    		 
      * Prior Insurance Company:          
      * Prior BI Limits:                
      * Prior Expiration Date:              
                               
                               
      GMAC FAMILY RELATIONSHIPS              
        GMAC Mortgage:  
    		             
        GMAC Auto Loan:  
    		             
        GMAC Auto Lease:
    		             
        GMAC Demand/Smart Note:
    		             
        GM Business Credit Card:
    		             
        GM Personal Credit Card:
    		             
        GM/GMAC Retiree:  
    		             
        GMAC Dealer Employee:
    		             
                               
                               
      ADDITIONAL INFORMATION              
        Number of additional insureds:          
    		 
        Does your agency have any inforce commercial lines policy for this applicant:
    		 
        Was this policy underwritten by a company affiliated with GMAC Insurance:
    		 
        How many individuals does the business employ:      
    		 
        How many of the individuals employed drive the vehicles listed on this policy:
    		 
        Do any of these scenarios apply:
    		 
        Is the insured a member of a nationally recognized business or trade association:
    		 
        How long has this agency controlled the account for this business:  
    		 
        Does the applicant operate over a regular route:      
    		 
        Is the applicant under contract to haul for a single firm:    
    		 
        Does the applicant haul his/her own cargo exclusively:    
    		 
        Are there additional drivers with access to the vehicles:    
    		 
                               
                               
        COVERAGES                    
        Term:  
    		             
        Pay Method:
    		             
        Pay Plan:
    		             
                               
        Bodily Injury / CSL:
    		           
        Property Damage:  
    		           
        UMBI - Non-Stacked:
    		           
        UIMBI - Non-Stacked:
    		           
        PIP Medical:  
    		           
        PIP Combined FPB:
    		           
        PIP Accidental Death:
    		           
        PIP Extraordinary Medical:
    		           
        PIP Funeral:  
    		           
        PIP Income Loss:  
    		           
        Hired Auto:  
    		           
        Non-Owned Liability:
    		           
        Comprehensive:  
    		           
        Collision:  
    		           
        Full Glass Coverage:
    		           
                             
                             
      AGENCY INFORMATION                
        Agency Name:        
                               
        Agency Address:        
                               
        Agency Phone:              
                               
        Agency Fax:              
                               
        Agency Contact:            
                               
        Contact E-Mail Address:          
                             
                             
                             
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