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Application Form

RESOLUTE 2000 BUS & COACH PROGRAM

Sender Information

After sending this application, an email will be sent to confirm receipt of this form. If you have not received the email within 24 hours, contact Cathy Tylus at 1-800-663-0787.

Sender information will be used to confirm application information.
* - denotes required field

Your name*

Your Email*

Your Information

Legal Name			Contact
Address			Tel.
City			Fax
Province
Postal Code

Additional names to be added			Mortgage or Lienholder

Fleet Information

Vehicle List + VIN's + RIN's + CVOR

Insurer/Agents 3 YR. Report Claim

MVR's of all drivers

Last Insurer's Name
Policy #		Expiry Date

Property Information

Location			Lot #
Concession			Municipality
Attach Copies of (1) Policies (2) Picture of Each Building If Available
Amount of Insurance Required
Buildings			Contents
Equipment
Other
Please specify
Business Interruption

Garage Information
Limit on Customers' Vehicles			# of Loaners
Max. Value of vehicles for sale			# of Dealer Plates
# of Mechanics

Operations
School Bus Revenue			Garage Revenue
Charter Revenue (other than school bus)			Other Activity Revenue
Describe Other Activities
Out of province/Country Revenue
Please Describe
U.S. ICC #			State Filed
Additional Requirements

Claims History (Date, Type, Fault & Amounts)

Has an insurer ever canceled or refused renewal?
Please indicate any exceptions
By pressing the 'Send Form' button at the bottom of this application you acknowledge that no extensions to standard form are required (e.g. excess economic loss) and limits as advertised only are hereby applied for. (Coverage is subject to the terms and conditions of the policy and this application is subject to acceptance by Marsh Canada Limited and the insurers represented in this program.)
COVERAGE EFFECTIVE FROM

Your Agreement

I authorize the Insurer to collect any credit rating, driver information, claims history concerning this application. I understand that I could negate the coverage applied for in this application if I give false or misleading information, or if I fail to disclose all particulars, or if I contravene a term of the contract, or commit fraud.

By pressing the 'Send Form' button at the bottom of this application you acknowledge that all that is expressed on this application is exact, and I am aware that any falsehood or change to the above could alter my quote.


Dated
Name*
Email*

If the application is complete and accurate to the best of your knowledge press the 'Send Form' button.