Fillable Application - Auto Daily Rental36-9612

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Application - Auto Daily Rental36-9612

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AUTO DAILY RENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Complete Current Rental Agreement (front and back)
• Vehicle Schedule showing Year, Make, Model and complete Vehicle Identification Number (VIN)
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
• Photograph – Each Location
• List of Additional Insureds, Loss Payees, and Certificate Holders (with addresses)
• For Property and General Liability proposal, attach specific ACORD applications*
* These coverage lines, if applicable and meet underwriting guidelines will be written under a separate policy.
GENERAL INFORMATION
1.
Name of Applicant:
2.
Address:
P.O. Box:
City:
State:
Zip Code:
Telephone Number:
3.
Website: www.
4.
Billing contact name:
Phone:
Name(s) of Principal(s):
Risk Management contact name:
Phone:
5.
Business is:
Individual
Partnership
Corporation
FEIN:
6.
Corporate system affiliation:
7.
Number of years in rental business and background of owner and manager(s) [Start-ups, please include
business plan and resume of owner and manager(s)]:
8.
Is this a seasonal operation?
Yes
No
If yes, provide further details:
9.
Number of company employees:
10.
Are employees allowed personal use of vehicle fleet?
Yes
No
11.
Does the Applicant secure a motor vehicle report on each employee?
Yes
No
Auto Daily Rental
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© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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12.
List of employees
Name
Date of Birth
Driver’s License Number
(For additional employees, please list employee information on a separate sheet and attach to application.)
13.
Locations
Location Address
(City, State)
Number of
Cars
Number of Trucks
(Over 10,000 lbs GVW)
Manager
APPLICANT’S OPERATIONS
1.
Does the Applicant have operations other than short term Auto rentals?
(Please indicate all that are applicable)
Yes
No
“Rent to Own” Rentals
Long Term Leasing
Body Shop
Repair Garage
Used Car Sales
Valet/Shuttle Service
Parking Facility
Limo Service
Motorcycle Rental
Motor Home Rental
Trailer Rental
Recreational Vehicle Rental
Other (please specify):
2.
Will the Applicant rent vehicles used to carry passengers for hire?
Yes
No
3.
Does the Applicant knowingly rent to individuals or companies that will be operating the
rental vehicle for use in a ride sharing or transportation network operation, such as, but not
limited to, Uber, Uber X or Lyft?
Yes
No
4. Will the Applicant be renting units using online peer to peer websites, such as, but not
limited to Turo or GetAround? Yes No
5. Are all vehicles in the fleet available for rent? Yes No
6.
Are all vehicles titled in the business name?
Yes No
7. Yes No Is the Applicant applying to insure vehicles other than those used for daily rental?
If yes, explain (attach vehicle schedule for these units):
(Coverage under this policy may not apply to these units and may need to be covered under a separate policy)
COVERAGE INFORMATION
1. Current Rate:
Policy Period: to
Current Carrier:
Rating Basis:
Method for premium calculation:
Scheduled PCPM Gross Revenue Unscheduled PCPM
Estimated gross revenue for the next twelve (12) months: $
Auto Daily Rental
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03/2020
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Policy Period Insurance Carrier Average Number of Units Time and Mileage
Gross Revenue
Cars Trucks
3. Has the Applicant ever had a liability deductible? Yes No
If yes, when: Deductible:
4. Limit of Liability
Current Coverage
Desired Coverage
(if same, write “same”)
Owner: $ $
Renter:
State Statutory Limits State Statutory Limits
**Uninsured Motorist $ $
**PIP $ $
*Comprehensive ($1,000 minimum ded) $ $
*Collision ($1,000 minimum ded) $ $
*Pick and Choose basis? Yes No
If yes, number of units per year:
Other:
**Does the Applicant currently reject Uninsured Motorist coverage/stacking option and PIP
when allowed by law?
Yes No
5. If requesting Physical Damage coverage, what security measures are taken to prevent theft?
BUSINESS / COUNTER PRACTICES
1. Describe the Applicant’s hiring and training practices for new personnel:
2. Does the Applicant use a training manual? Yes No
3. How are employees paid?
4. Business hours:
5.
Present counter practices: (brief description) (Attach sample of each rental contract currently in use.)
6. Age limitation, if any:
7. Rental customer:
Type of rental (indicate % of your business in each category):
Personal % Business % Insurance Replacement %
Military % Other (specify): %
2.
No
Prior carrier information / exposure data: Previous experience (past 3 full years, plus current year).
Attach currently-valued loss runs.
Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes
Auto Daily Rental
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03/2020
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8.
Percentage of rentals using corporate account credentials: %
Are system corporate accounts afforded higher limits of liability?
Yes
No
If yes, what limits are provided to corporate accounts?
9.
Credentials: How does the Applicant qualify a renter?
10.
How are additional authorized drivers qualified?
Relationship:
11.
How are military rentals qualified:
12.
How are foreign drivers qualified?
13.
Is there a place on the contract for renter’s birth date?
Yes
No
14.
Does the Applicant perform a signature comparison?
Yes
No
15.
Does the Applicant verify a phone number on local rentals?
Yes
No
16.
Are all rental contracts secured with credit cards? If not:
Yes
No
What percentage of rentals contracts are secured with cash? %
Explain counter procedures for accepting cash rentals:
17.
Will the Applicant rent to someone using another person’s credit card?
Yes
No
18.
Does the Applicant rent without reservations?
Yes
No
19.
Does the Applicant accept all reservations?
Yes
No
20.
Does the Applicant ask where the vehicle will be driven and what its use will be?
Yes
No
21.
Does the Applicant require renter to provide proof of applicable insurance?
Yes
No
If yes, how does the Applicant qualify proof of insurance?
22.
Does the Applicant advertise?
Yes
No
If yes, where:
Auto Daily Rental
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03/2020
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23.
Does the Applicant sell CDW (collision damage waiver)?
Yes
No
24.
Does the Applicant sell SLI (Supplemental Liability Insurance) or like product?
Yes
No
25.
Does the Applicant sell any other form of primary liability insurance?
Yes
No
If yes, explain:
FLEET INFORMATION
1.
Fleet description – average number or percentage (attach current fleet list):
Full size:
Intermediates:
Compacts:
Luxury:
Service Vehicles:
Trucks:
Cargo Vans:
Passenger Vans:
Number of Passengers:
Other:
Percentage of vehicles
Owned %
Leased %
*Describe any units over 10,000 lbs. GVW (attach list including GVW):
*Describe any units over 20,000 lbs. GVW (attach list including GVW):
* Supplemental Truck Application must be completed (see below)
2.
Describe briefly the maintenance procedure conducted prior to and after rental:
3.
Are maintenance records kept for each vehicle in fleet?
Yes
No
If yes, explain:
4.
Who performs the maintenance and repairs of vehicle fleet?
Auto Daily Rental
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03/2020
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SUPPLEMENTAL TRUCK RENTAL APPLICATION
1.
Are all trucks available for rental?
Yes
No
2.
Does the Applicant use its trucks and drivers to haul cargo for the company or other
companies?
Yes
No
3.
Does the Applicant rent any trucks that are: (check all that apply)
Tractor Trailers
Dump Trucks
Flat Bed or Stake Body
Refrigeration
Mobile Equipment
Dual Axel Drive
Tank Trucks
Petroleum Product Haulers
Waste Disposal or Hazardous Material Haulers
Passenger Vans
4.
Does the Applicant provide employees as drivers with rental trucks?
Yes
No
5.
Are any special drivers’ licenses required to operate any trucks other than a private
passenger licenses? If yes, describe:
Yes
No
6.
What percentage of rentals are to individuals? %
What percentage are rentals to businesses?
%
Other:(describe)
7.
Does the Applicant require a driver test prior to rental?
Yes
No
8.
Does the Applicant require a certificate of insurance from the rentee providing primary
rentee coverage?
Yes
No
Does the Applicant require the rentee’s insurance carrier to name you as an additional
insured?
Yes
No
9.
What is the average radius of haul of your rental trucks?
What is the maximum radius of haul of your rental trucks?
10.
Is the Applicant required to obtain PUC, ICC, FHWA or other filings as owner of rental
trucks?
Yes
No
If yes, in what jurisdictions must you file?
11.
What is the maximum limit of liability provided to rental clients: $
Auto Daily Rental
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12.
Does the Applicant rent to any companies hauling gasoline, oil petroleum products,
waste materials, or hazardous material?
Yes
No
If yes, describe:
13.
List the names of your last five rental customers or five largest customers:
a.
b.
c.
d.
e.
14.
What types of cargo are hauled by your most frequent rental clients?
15.
How often are the Applicant’s trucks services?
16.
Does the Applicant keep records of each truck’s maintenance history?
Yes
No
17.
Does the Applicant employ mechanics to service its trucks?
Yes
No
If yes, does the Applicant service any trucks that it does not own or lease?
Yes
No
18.
Does the Applicant contract for service from a dealership or service company?
Yes
No
If yes, what company?
Auto Daily Rental
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03/2020
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NA
ME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Auto Daily Rental
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03/2020
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