Fillable Application - School Bus Contractor36-11554

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Application - School Bus Contractor36-11554

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SCHOOL BUS CONTRACTOR APPLICATION
GENERAL INFORMATION
Applicant’s Name:
Business Address:
City:
State:
Zip Code:
List all of the Applicant’s location addresses:
Effective Date:
Contact and Phone Number for Inspection:
Email:
Website: www.
Federal ID # (FEIN):
Years In Business:
Type of Entity:
Partnership
Corporation
Other:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SECTION I – APPLICANT’S INFORMATION
1.
Are there operations of the Applicant that are not related to school bus service?
Yes
No
2.
Does the Applicant operate as a subsidiary of another company?
Yes
No
3.
List all other named insureds or affiliated companies, if any:
4.
Years the Applicant has been in business:
5.
Has the business ever operated under a different name?
Yes
No
6.
Breakdown of vehicles by size.
1 to 8 passenger:
# Wheelchair Equipped:
9 to 20 passenger:
# Wheelchair Equipped:
21 to 60 passenger:
# Wheelchair Equipped:
61+ passenger:
# Wheelchair Equipped:
Private Passenger Vehicles:
# Wheelchair Equipped:
Service Vehicles:
# Wheelchair Equipped:
7.
Has there been a significant change of fleet size in the past 5 years (increase or decrease over
20%)?
Yes
No
8.
Is the Applicant a member of the National School Transportation Association?
Yes
No
SECTION II - OPERATIONS
1.
Description of operations:
Rural
Suburban
Urban
2.
Radius of operations:
School Bus Contractor Application
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03/2020
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3.
Please list the following:
Major Contracts
% of Revenue
Derived
School Districts Served
%
%
%
%
%
%
Please list any additional School Districts separately.
4.
Is 90% or more of the Applicant’s revenue derived from the operation of school buses?
Yes
No
5.
What percentage of the Applicant’s revenue comes from:
Type of Service
% of Revenue
Charter Bus Services
%
Sightseeing / Tour Services
%
Taxi Services
%
Shuttle Services
%
Limousine Services
%
Medical Transportation
%
Sporting Events
%
Concerts
%
6.
Has the Applicant won or lost any contracts within the last three (3) years?
Yes
No
7.
List all after school activities (check all that apply):
Field Trips
Athletic Events
Summer Camps
Other:
8.
Does the Applicant rent / lease / loan buses without drivers to others?
Yes
No
If yes:
a.
Do the parties named carry Automobile Liability Insurance?
Yes
No
b.
Is there a Hold Harmless / Indemnification Clause?
Yes
No
c.
Is the Applicant named as an Additional Insured?
Yes
No
SECTION III – SAFETY PROGRAM
1.
Does the Applicant have a formal written safety program? (Please provide a copy)
Yes
No
2.
Are regular safety meetings held?
Yes
No
If yes, how often?
3.
Is there any driver post hiring driver training?
Yes
No
If yes, please describe:
4.
Does the Applicant have an Accident Review Committee and disciplinary procedure for drivers
with moving violations?
Yes
No
If yes, please describe:
5.
Does the Applicant provide a drug / alcohol free workplace?
Yes
No
If yes, please describe:
SECTION IV - AUTOMOBILE
1.
Is there any personal use of the vehicles?
Yes
No
If yes, please describe the Applicant’s policy:
School Bus Contractor Application
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2.
Are family members allowed to use company vehicles?
Yes
No
If yes, please describe the Applicant’s policy:
3.
Do employees take company vehicles home in the evening?
Yes
No
If yes, please describe the Applicant’s policy:
SECTION V – VEHICLE INFORMATION
1. Provide addresses where all vehicles are stored and provide the number of units stored at that location.
Location Address # of Units Stored
2. Is there a flooding exposure? Yes No
If yes, please describe the plan to move the buses:
3. Please describe the lot security where the Applicant’s buses are parked:
4. Who performs the maintenance?
a. If the Applicant performs the maintenance, how many mechanics are employed?
b. What is the mechanics’ payroll: $
5. Are the mechanics trained or ASE certified? Yes No
If yes, please explain:
6. Please describe the maintenance program in effect and how it is documented:
7. What determines the need for maintenance of a vehicle?
4. Yes No Does the Applicant have a formal driving policy in place with MVR standards?
If yes:
a. Is driving policy communicated in writing to all employees? Yes No
b. Yes No Is a signed acknowledgement form kept on file?
If yes, please provide a copy of signed acknowledgement.
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
5. Does the Applicant have GPS tracking capability? Ye
s No
6. Are vehicles / equipment on a scheduled maintenance program? Yes No
7. Is a log maintained listing defects and repairs? Yes No
8. At what location are the majority of the Applicant’s vehicles parked when not in use?
School Bus Contractor Application
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9. Is the Applicant committed to any contract in which the Applicant has to provide the maintenance,
insurance or a driver for a vehicle that the Applicant does not own?
Yes No
If yes, please describe:
SECTION VI – HIRING PROCEDURES
1. Does the Applicant hire drivers under the age of 25? Yes No
2. Are all drivers properly licensed and registered in accordance with State and Federal Guidelines? Yes No
3. Do all of the Applicant’s drivers who operate school buses / vans / coaches have CDL licenses
and the proper school bus passenger endorsements?
Yes No
4. Is a written application for employment completed? Yes No
5. Are MVR’s ordered and reviewed:
Quarterly Semi-Annually Yearly When Hired
6. Are previous Employers contacted and references checked? Yes No
7. Is there a company supervised road test that is given to all drivers? Yes No
8. Is there an employee drug test? Yes No
9. Is there a written driving exam? Yes No
10. Is there a physical examination? Yes No
11. Is there a minimum number of years’ experience required for bus driving? Yes No
12. Are driver records maintained for all drivers for a minimum of three (3) years? Yes No
13. What is the average length of employment for drivers?
14. Describe driver training and incentive program:
SECTION VII - TRANSPORTATION
1. Does the Applicant transport individuals with special needs? Yes No
2. Are monitors provided when transporting special needs student? Yes No
3. Are drivers / staff trained in the handling of special needs students? Yes No
4. If wheelchair equipped, do all lifts / ramps comply with ADA accessibility requirements? Yes No
SECTION VIII – PRIOR LOSS EXPERIENCE AND COVERAGE INFORMATION
• Attach currently valued loss runs from previous insurance carriers for each of the past five (5) policy periods
• Please provide details on any loss occurrence that exceeds $50,000 or involves a fatality or serious injury
separately
Current Policy Period
Year 20
Prior Four (4) Policy Periods
Year 20 Year 20 Year 20 Year 20
Insurance Carrier
Policy Effective Date
Limit of Liability $ $ $ $ $
Deductible or SIR $ $ $ $ $
Annual Premium $ $ $ $ $
Total Losses $ $ $ $ $
Number of Vehicles
8.
Yes No
Are all of the Applicant’s vehicles titled in the name of the Applicant’s corporation listed on the
application for insurance?
If not, please list the name on the registration and the VIN of the vehicle:
Name on Registration VIN
School Bus Contractor Application
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SECTION IX – FILING INFORMATION
1. Does the Applicant’s operation require FMSCA authority? Yes No
If yes, please provide: MC #: DOT #:
Please explain why FMSCA authority is needed:
2. What is the current status of the authority?
3. Please show how the Applicant’s name reads on the filing:
4. Has the Applicant ever had its filing revoked? Yes No
5. Does the Applicant require Form E filings? Yes No
If yes, please explain why a Form E is needed (and for which states):
6.
Please list the agency where the form E must be filed, along with the address. Attach a letter
from the filing authority approving the filing.
7. How many vehicles do not have an SB or SV plate?
8. What are the Applicant’s receipts from non-school transportation: $
9. Please describe all non-school transportation that requires a filing:
SECTION X – ABUSE & MOLESTATION
1. Does the Applicant keep a copy of the criminal background checks in a secure location with
limited access?
Yes No
2. Does the Applicant order the FBI fingerprint tests on all new employees and keep a copy of the
results in a secure location?
Yes No
3. Does the Applicant’s employment application include questions regarding whether the employee
has ever been convicted of any crime, including sexual – or child abuse-related offenses?
Yes No
4. Are drivers prohibited from driving until background checks are received? Yes No
5. Is there a written code of conduct for drivers with regard to interacting with children? Yes No
6. Is there a written protocol in place to handle suspected or observed abuse or molestation? Yes No
7. Does the Applicant require field trips to have chaperones, placing chaperones in the back, center
and front seats?
Yes No
8. Are field trip chaperones teachers or well-respected members of the community? Yes No
9. Does the Applicant have cameras on all of the buses? Yes No
10. On buses that transport a wide range of students, does the Applicant place the younger students
in the front seats?
Yes No
11. Do high school students only sit two to a seat? Yes No
12. Does the Applicant require all special needs students to sit in the front seats? Yes No
13. Are aides required on buses that transport special needs students? Yes No
14. Does the Applicant train their drivers to recognize suspected abuse among students? Yes No
15. Does the Applicant have and use student conduct forms and does the school district support their
use?
Yes No
16. Does the school district have zero tolerance for bullying and are drivers trained to recognize a
bully?
Yes No
17. Will the Applicant put an aide on the bus if necessary to observe student conduct? Yes No
1. Yes No Has the Applicant’s insurance ever been obtained through an Assigned Risk Plan?
If yes, please explain:
2. Has any insurance company, during the past 4 years, cancelled or refused to renew the
Applicant’s Automobile Insurance Coverage? (Not Applicable in Missouri) Yes No
School Bus Contractor Application
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18. In the past, has the Applicant’s company ever had an allegation of abuse or misconduct? Yes No
19. Does the Applicant conduct formal staff training on child / sexual abuse, including how to
recognize the signs? Yes No
20. Does the Applicant require their drivers to wear identification that can be seen? Yes No
21. Does the Applicant perform background checks on mechanics or any substitute driver? Yes No
22. Limit requested: $100,000 $250,000 $500,000 $1,000,000
Note: If $500,000 or $1,000,000 limits are requested, background checks are required every
three years and a pre-inspection is required on a new quote.
School Bus Contractor 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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
_______
______________________________________________________
SIGNATURE DATE
SEC
TION 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)
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03/2020
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