Fillable Application - Lessors Contingent And Excess36-11264

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Application - Lessors Contingent And Excess36-11264

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LESSORS CONTINGENT AND EXCESS LIABILITY
LESSORS CONTINGENT PHYSICAL DAMAGE
SUBMISSION REQUIREMENTS
•
Current complete copy of lease agreement
•
Currently valued insurance company loss runs for the current policy period plus three (3) prior years
•
Copy of all letters for insurance follow-up
•
Complete application and any applicable supplement(s)
SECTION I - GENERAL INFORMATION
1.
Corporate and d/b/a Name and Address:
2.
Telephone number:
3.
Contact Name/Title:
4.
Billing Contact Name:
5.
Owner’s Name:
6.
FEIN:
7.
Website: www.
SECTION II - FLEET INFORMATION
1.
What is the total number of units in your fleet?
Cars & Light Commercial number of units:
Other: (please describe)
Trucks over 12,500 lbs:
Trailers:
2.
What percentage of your leases are consumer leases? %
3.
What percentage of your leases are commercial fleet leases? %
List the names of your largest commercial fleets:
4.
What is the total number of lease contracts in your portfolio?
5.
What % of your lessees are rated:
% A Credit
% C Credit
% B Credit
% D Credit
6.
Yes
No
If yes, please explain:
7.
How many lease terminations do you anticipate over the next twelve (12) months?
8.
How many new leases do you anticipate over the next twelve (12) months?
9.
Lessors Contingent and Excess Liability
Lessors Contingent Physical Damage
Page 1 of 4
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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10. Do you understand that it is your responsibility (and a condition precedent to coverage) to maintain,
in your files, a valid certificate of insurance from the lessee’s insurer? Yes No
11. Yes No Do you presently use an independent tracking service to follow up on certificates?
If yes, what company provides this service?
12. Do you understand that units leased for less than one year are not covered by Lessor’s Contingent
coverages? Yes No
13. Are vehicles leased to principal operators under 21 years of age? Yes No
14.
Do you directly market to customers who will be operating vehicles used for ride sharing or
transportation networks, such as but not limited to, Uber, Uber X or Lyft?
Yes No
15. Yes No Do you deliver vehicles for lease prior to receipt of Certificate of Insurance?
If yes, do you verbally verify the lessee’s coverage with their insurer?
Yes No
17.
How many units in your fleet are over $45,000 in value?
How many units in your fleet are over $75,000 in value?
18.
Yes No Do you have plans to enter new states of operation or increase emphasis in certain states?
If yes, which states?
19.
What is the term of the lease? Minimum Maximum
20.
Do you accept any self insured lessee or governmental/postal lessee insured through the Federal
Tort Act? Yes No
21.
Yes No Do you offer a Primary Lease Program that includes insurance for the Lessee?
If yes, what carrier insures that primary program?
22.
Do you perform the maintenance on the leased unit? Yes No
a. If yes, what percentage of the leased units do you perform the maintenance on? %
b.
Yes No
Do you have a Garage Liability or General Liability policy that provides coverage for
maintenance on all work performed?
If yes: Carrier:
Liability Limit: $
23.
Indicate the current number of vehicles garaged in each state or attach your own summary or
computer print out that includes this information:
State # of Vehicles State # of Vehicles State # of Vehicles State # of Vehicles
AL IN NV TN
AK IA NH TX
AZ KS NJ UT
AR KY NM VT
CA LA NY VA
CO ME NC WA
CT MD ND WV
DE MA OH WI
DC MI OK WY
FL MN OR PUERTO RICO
GA MS PA CANADA
HI MO RI TOTAL
ID MT SC
IL NE SD
Check coverage desired:
Contingent Liability
Contingent Excess liability : Limit: $
Contingent Physical Damage: 1000/1000 Deductibles 2500/2500 Deductibles
If this is a renewal policy, limits and coverages will be quotes as expiring. Any changes to the expiring
Coverages/limits must be requested in writing.
16. Yes No Are all vehicles registered to the lessee?
If
no, to whom are they registered?
Lessors Contingent and Excess Liability
Lessors Contingent Physical Damage
Page 2 of 4
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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SECTION III - INTERIM LIABILITY AND PHYSICAL DAMAGE
New business or Renewal – Complete separate Interim application
LESSORS CONTINGENT LIABILITY AND EXCESS LIABILITY LESSORS
CONTINGENT PHYSICAL DAMAGE
NOTICE OF EXCLUDED VEHICLES
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
BROKER OF RECORD AUTHORIZATION
– The signing of this application does not bind the insured or the
Insurance Company to renewal of this insurance. It is agreed that the information contained herein shall be the
basis of the renewal contract should one be issued. It is further agreed that should any of the information or data
provided herein change, or should the risk management procedures currently in place be modified or changed, the
insured will notify the producer of such changes within ten (10) days thereof.
SECTION IV - SUPPLEMENTAL TRUCK / TRAILER CONTINGENT APPLICATION
1. Do you use your trucks and drivers to haul cargo for your company or other companies?
Yes
No
2. Do any of your leased units fall into these classifications / categories?
a.
Tractor Trailers
Yes
No
b. Dump Trucks
Yes
No
c. Flat Bed or Stake Body
Yes
No
d. Refrigeration
Yes
No
e. Mobile Equipment
Yes
No
f. Dual Axle Drive
Yes
No
g. Tank Trucks
Yes
No
h. Petroleum Product Haulers
Yes
No
i. Waste Disposal or hazardous Material Haulers
Yes
No
j. Passenger Vans
Yes
No
3. What is the average radius of haul of your lease trucks? miles
What is the maximum radius of haul of your lease trucks? miles
4.
Are you required to obtain PUC, ICC or other filings as owner of your lease trucks?
,I\HVLQwhat jurisdictions must you file?
Yes
No
5. Do you lease to any companies hauling gasoline, oil, petroleum products, waste materials, or
hazardous materials?
If yes, please describe.
Yes
No
6.
What types of cargo are hauled by your five (5) largest lease clients?
7.
How often are your trucks serviced?
8.
Do you keep records of each truck’s maintenance history?
Yes
No
9.
Do you employ mechanics to service your trucks?
Yes
No
If yes, do you service any trucks that you do not own or lease?
Yes
No
10.
Do you contract for service from a dealership or service company?
Yes
No
If yes, what company?
11.
What percentage of your lease fleet are full-service leases? %
1.
Are any of the units in your fleet leased or used for the following purpose?
a.
Commercial trucks with a GVW over 12,500 lbs.?
b.
Taxicab, bus, limo service or other public livery use?
c.
An emergency ambulance or a fire department or law enforcement agency auto?
d.
As a driver education or training vehicle?
e.
As a long haul public freight carrier?
Please note that coverage for these vehicles is not provided in our standard policy.
____________________________ _____________________________
Insured’s Signature Date Producer’s Signature Date
Lessors Contingent and Excess Liability
Lessors Contingent Physical Damage
Page 3 of 4
© 2020 Philadelphia Consolidated Holding Corp.
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)
Lessors Contingent and Excess Liability
Lessors Contingent Physical Damage
Page 4 of 4
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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