Fillable Application - Chauffeured Transportation36-10633

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Application - Chauffeured Transportation36-10633

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CHAUFFEURED TRANSPORTATION INSURANCE APPLICATION
SUBMISSION REQUIREMENTS
• Upon binding, an application signed by both the Applicant and Producer is required.
• Currently valued insurance company loss runs for the current and prior three (3) years
• An updated drivers list with current MVRs (less than 3 months old) for each driver
• An updated Vehicle Schedule
• New ventures must provide a resume with the last three (3) years of employment listed
SECTION I – GENERAL INFORMATION
1.
Name of Limousine Operation (include DBA):
2.
Company Type:
Corporation
Other:
3.
Mailing Address:
Business Telephone:
Fax:
Garage Address:
Email Address:
Website Address:
4.
Contact Person:
Title:
5.
Number of Years in Business:
Number of Employees:
6.
Does the owner have other employment?
Yes
No
If yes, please explain:
7.
ICC/PUC docket number, if applicable:
8.
FEIN (Federal Employer Identification Number):
SECTION II - COVERAGE INFORMATION
LIABILITY
COVERAGES
LIMIT
PHYSICAL DAMAGE
COVERAGES
PHYSICAL
DAMAGE
DEDUCTIBLE
Auto Liability (Combined Single Limit)
$
Comprehensive:
$
Personal Injury Protection (PIP)
$
Collision:
$
Uninsured Motorist Protection (UM)
$
Underinsured Motorist Protection (UIM)
$
Employer’s Non-Ownership Liability
$
Hired Auto Liability
$
SECTION III - OPERATIONS INFORMATION
Estimated Mileage
Gross Receipts
For Proposed Coverage Period:
$
Current Year:
$
Prior Year:
$
1.
Type of Garaging:
Indoor
Outdoor
Fenced
Lighted
Security Guard
Other:
2.
Do employees take vehicles home?
Yes
No
If yes, are they garaged?
On Street
Off Street
Chauffeured Transportation
Insurance Application
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03/2020
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3.
Are vehicles serviced and inspected?
Yes
No
If yes, by whom?
How often?
4.
Does the Applicant own or operate any equipment not listed on the schedule?
Yes
No
If yes, please explain:
5.
Are your vehicles equipped with a two-way radio?
Yes
No
If yes, what are the radios used for?
6.
7.
Does the Applicant have GPS tracking capability?
Yes
No
8.
Are all of the Applicant’s conversion vehicles QVM certified?
Yes
No
If yes, by whom?
If no, please explain:
9.
What was the Applicant’s longest round-trip destination in the last twelve (12) months?
10.
What is the Applicant’s three (3) most frequent destinations and percentage of trips to those destinations:
Destination
Percentage
City/State:
%
City/State:
%
City/State:
%
11. What percentage of your trip(s) are: Airport:
%
Corporate: %
Weddings/Funerals : %
Prom / Night-on-the-Town: %
Other %
Describe:
12.
What percentage of your reservations is made twenty-four (24) hours in advance?
13.
Do the Applicant’s vehicles ever transport professional athletic teams or entertainment groups?
Yes
No
If yes, please explain:
14.
What is the Applicant’s expected Cost of Hire for hired autos next year: $
15.
Yes
No
Does the Applicant lease vehicles from others?
If yes, what percentage:
%
Yes
No
Yes No
Yes No
SECTION IV - DRIVER INFORMATION
1. Within the last twelve (12) months, how many drivers has the Applicant replaced: Added:
2. Does the Applicant’s driver selection procedure include drug testing? Yes No
3. What is the minimum age of drivers?
4. Does the Applicant have a driver recruitment program? Yes No
If yes, please explain:
5. Does the Applicant provide Workers’ Compensation coverage for all their drivers and all other
employees?
Yes No
If yes, specify insurance carrier:
If no, provide an explanation:
6. Are all drivers your employees? If no, provide an explanation: Yes No
7. Does the Applicant have a formal driving policy in place with MVR standards? Yes No
If yes:
a. Is driving policy communicated in writing to all employees? Yes No
b. Is a signed acknowledgment form kept on file? Yes No
If yes, please provide a copy of signed acknowledgment.
c. Do driving standards include the following:
i. No major violations including DUI, racing, hit and run, speeding in excess of 20 mph
over posted speed limit, manslaughter?
Yes No
ii. No more than 2 moving violations within past 3 years? Yes No
iii. No more than 1 at fault accident within past 3 years? Yes No
8. How often does the Applicant check MVR reports?
%
Does the Applicant have Drive-Cam or any other
recording devices on your vehicles?
Yes No
Drive-Cam
Other:
16. Does the Applicant lease or
rent out vehicles to others (without driver)?
17. Does the Applicant use or hire Owner-Operators?
18. Does the Applicant or any of its drivers utilize Transportation Network Company Mobile
Applications such as but not limited to Uber, Uber-X, or Lyft?
Chauffeured Transportation
Insurance Application
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9.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
10.
Describe any ongoing training provided to drivers:
11.
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a.
Are the driving policy and standards for these drivers the same as in questions 1-3?
Yes
No
b.
Does the Applicant require these employees to have adequate personal insurance limits?
Yes
No
SECTION V - PRIOR INSURANCE HISTORY*
POLICY PERIOD
INSURANCE
COMPANY
NO. OF
LIMOS
OPERATED
PREMIUM
LOSS HISTORY
MO
DAY
YR
AUTO
LIABILITY
PHYSICAL
DAMAGE
GENERAL
LIABILITY
TOTAL $
INCURRED
NO. OF
CLAIMS
*Please attach details of all losses that exceeded $25,000 as well as any gaps in insurance coverage.
1.
Is the Applicant’s present policy being cancelled or non-renewed? If yes, please explain:
Yes
No
2.
Has the Applicant’s insurance ever been obtained through an Assigned Risk Plan?
Yes
No
If yes, please explain:
3.
Has the Applicant ever filed or are planning to file for reorganization or bankruptcy?
Yes
No
4.
Provide the name(s) of any public transportation entity(ies) not covered under this application in
which the named insured or any of its officers, directors, partners, or stockholders have a direct
or indirect ownership interest:
5.
Except for encumbrances, are all autos owned by, leased to, or registered to the Applicant?
Yes
No
If no, please explain:
6.
Please explain any prior gaps in insurance coverage:
SECTION VI - VEHICLE SCHEDULE
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value: Cost New $
or
Stated Value $
Personal Use?
Yes
No
Comprehensive
Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto
Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value: Cost New $
or
Stated Value $
Personal Use?
Yes
No
Comprehensive
Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto
Assigned Driver:
Chauffeured Transportation
Insurance Application
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03/2020
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#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value: Cost New $
or
Stated Value $
Personal Use?
Yes
No
Comprehensive
Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto
Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value: Cost New $
or
Stated Value $
Personal Use?
Yes
No
Comprehensive
Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto
Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value:Cost New $
or
Stated Value $
Personal Use?
Yes
No
Comprehensive
Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto
Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value:Cost New $
or
Stated Value $
Personal Use? Yes
No
Comprehensive Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value:Cost New: $
or
Stated Value: $
Personal Use?
Yes
No
Comprehensive Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto Assigned Driver:
#:
Year:
Make:
Model:
GVWR:
Radius:
Color:
Length of Stretch
Number of Passengers:
Garage Location:
VIN:
Value:Cost New $
or Stated Value: $ Personal Use?
Yes
No
Comprehensive Coverage:
$1,000
$2,500
Collision Coverage:
$1,000
$2,500
Loss Payee
Additional Insured – Leased Auto Assigned Driver:
SECTION VII - LIEN HOLDER SCHEDULE
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Chauffeured Transportation
Insurance Application
Page 4 of 7
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03/2020
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Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
Loss Payee
Additional Insured
Vehicle Number for App Schedule:
Entity Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Contact:
SECTION VIII - DRIVER INFORMATION SCHEDULE
Please include ALL drivers for Named Insured
No.
Name as it
Appears on
Drivers License
Street Address
City, State, Zip
Date of Birth
Drivers License
Number
Date of
Hire
No. Yrs
Driving
Limos
Full or
Part
Time
1
2
3
4
5
6
7
Chauffeured Transportation
Insurance Application
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No.
Name as it
Appears on
Drivers License
Street Address
City, State, Zip
Date of Birth
Drivers License
Number
Date of
Hire
No. Yrs
Driving
Limos
Full or
Part
Time
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Chauffeured Transportation
Insurance Application
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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)
Chauffeured Transportation
Insurance Application
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03/2020
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