Does the base have a Workers Compensation Carrier?

I understand that American Transit does NOT provide the Workers Compernsation Coverage. Failure to carry proper Workers Compensation Coverage is a violation of law and a breach of the policy.

Do you have a Fixed Work Schedule?

Signature of Drivers

Sign of Producer

Sign of Witness

INSURED'S AFFIRMATION

I hereby understand that my insurance and premium is based on information given on the application(s) for which I signed on

I understand that I must report all drivers for approval prior to allowing them to operate my vehicle(s)

I further understand that failure to report drivers prior to operating vehicles will result in cancellation of coverage based on concealment of information which is outlined in the New York Fraud Statement (IL 01 83 04 98)

My premium is based on territory _ which is where I operate my vehicle(s) at least 80% of the time. I understand that if I operate in a territory other than the territory listed above my premium may be increased.

My vehicle is

I currently

I currently

I understand that American Transil does NOT provide the Workers Compensation Coverage. Failure to carry proper Workers Compensation Coverage is a violation of law and a breach of the policy.

NEW YORK AUTOMOBILE SUPPLEMENT APPLICATION

The following is a generel description of statutory and supplemant Uninsured/underinsured Motorists Coverge available in New York.Only your policy provide you with a complete description of coverages and their limitations.

STATUTORY UNINSURED MOTORISTS COVERAGE

Under new york state law, you are requested to have statutory uninsured motorists coverage at a minimum limit of $25,000 per person /$50,000 per accident bodily lnjury which does not result in death;$50,000 per person/$100,000 per accident bodily lijury which does result in death.The same limit must apply to all the autos on your policy.

SUPPLEMENTARY UNINSURED/UNDERINSURED MOTORISTS(SUM)COVERAGE

SUM coverage provides increased uninsured/underinsured motorists coverage.By purchasing SUM coverge ,you and any covered person under the policy can be protected for bodliy injury up tp the limited of SUM Coverged purchased. You can aslo resive form your own insurer payment for bodliy injury sustained due to neggligence of the other motor vechicie's owner or operator. This coverage also provid ypu and any coverde perdon bodliy injury protection if involed in an accident with a driverwhose bodliy injury liability limited are less then the bodliy injury liability limits you have selected.

court in many states have held that this coverages are valuable coverage which are available for relatively modest premium.

statutory Uninsured Motoriser Coverage will be afforded to you.You have the option to select Supplementary Uninsured/Coverage Motorist coverage,which includes statutory Uninsured Motorise Coverge.Please mark your selection below.

Selection of Coverage

I wish to purchase SUM coverage at the limits indicated below: