Fillable Additional Application Supplement (Risk Placement Services, Inc.)

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Additional Application Supplement (Risk Placement Services, Inc.)

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Additional Application Supplement
Submission Number:
Name
DRIVER INFORMATION
(Last, First, Middle)
Date of Birth
License Number
State
Must be Completed for All Drivers
Date of Hire
Driver Name
# Yrs. Driving
Similar Equip.
DRIVER VIOLATION HISTORY - Past 3 Years
(Last, First, Middle)
Violations/Convictions
#
Driver Name
Accidents
Speeds
Other Than Speeds
# Minor
# Majors
Date of Most Recent
Moving Violation/Conviction
# Minor
DRIVER EMPLOYMENT HISTORY
Prior Employment and Full Address
Employment
of Unit
Driver Name
(Last, First, Middle)
Dates of
Type
If you have not had insurance for the past two years in your name, provide three years employment history for each driver.
(Use form TF-079 for additional drivers.) Do not indicate "self-employed" unless you have had insurance in your name.
INSURANCE HISTORY AND LOSS EXPERIENCE
Prior Carrier Effective Dates
Prior Carrier Name
Policy Number
# Units
Insured
#
Losses
Coverage
Type*
*Type: P=Phys. Dmg. C=Cargo L=Prim. Liab. N=Non-Trk. Liab. GL=Genl Liab. IM=Inland Marine
to
to
to
Accident
Amount of Accident
Description
Date of
LOSS HISTORY - Past 3 Years (including Drivers no longer employed)
Driver Name
(Last, First, Middle)
SCHEDULE OF AUTOS
All units you own or are leased to you must be scheduled and insured if filings are to be made.
N-3077 (6/14)
Page
of
© 2014 The Travelers Indemnity Company. All rights reserved.
1 2
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Make
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVM/CMC
Ownership:
Owned
Employee Owned
Leased Without Driver
Leased w/ Driver Incl. Non-Trucking
Leased w/ Driver Excl. Non-Trucking
Leased With Driver
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
PUBLIC
AUTO
ONLY
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Make
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVM/CMC
Ownership:
Owned
Employee Owned
Leased Without Driver
Leased w/ Driver Incl. Non-Trucking
Leased w/ Driver Excl. Non-Trucking
Leased With Driver
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
PUBLIC
AUTO
ONLY
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Make
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVM/CMC
Ownership:
Owned
Employee Owned
Leased Without Driver
Leased w/ Driver Incl. Non-Trucking
Leased w/ Driver Excl. Non-Trucking
Leased With Driver
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
PUBLIC
AUTO
ONLY
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Make
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVM/CMC
Ownership:
Owned
Employee Owned
Leased Without Driver
Leased w/ Driver Incl. Non-Trucking
Leased w/ Driver Excl. Non-Trucking
Leased With Driver
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
PUBLIC
AUTO
ONLY
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Make
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVM/CMC
Ownership:
Owned
Employee Owned
Leased Without Driver
Leased w/ Driver Incl. Non-Trucking
Leased w/ Driver Excl. Non-Trucking
Leased With Driver
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
PUBLIC
AUTO
ONLY
ADDITIONAL INTERESTS
Unit #
Address
State
Name
City
ZIP Code
Type*
Type*:
*Vehicle Type Legend - Refer to primary Application for codes.
AI - Additional Insured AL - Lessor; Additional Insured and Loss Payee LP - Loss Payee
LI - Leased with Driver Including Non-Trucking
LX - Leased with Driver Excluding Non-Trucking
N-3077 (6/14)
Page
of
© 2014 The Travelers Indemnity Company. All rights reserved.
2 2
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Additional Application Supplement (Risk Placement Services, Inc.)

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Completed 23 November 2020

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