Fillable Application Contingent Liability (Bobtail & Deadhead) Individual/Proprietorship Partnership (Risk Placement Services, Inc.)

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Application Contingent Liability (Bobtail & Deadhead) Individual/Proprietorship Partnership (Risk Placement Services, Inc.)

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Contingent Liability
Application
(Bobtail & Deadhead)
COLUMBIA INSURANCE COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY
NATIONAL INDEMNITY COMPANY OF MID-AMERICA
NATIONAL INDEMNITY COMPANY OF THE SOUTH
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
Policy Term From:
To:
1. Name (and "dba")
Individual/Proprietorship Partnership Corporation Other Business Phone Number
2. Mailing Address City State Zip
3. Premises Address City State Zip
4. Person to contact for inspection (name and phone number)
5. Have you ever had insurance with one of the companies listed at the top of this page? Yes No
If yes, policy number(s)
Effective Date(s)
DESCRIPTION OF OPERATIONS
6. Describe Business
Years Experience New Venture? Yes No Seasonal? Yes No
7. Is this your primary business?
Yes No If no, explain
8. Have you ever filed for bankruptcy? Yes No If yes, when Explain
9. Gross Receipts Last Year Estimate for Coming Year Business for sale? Yes No
10. Do you operate in more than one state?
Yes No If yes, list states
11. Show largest cities entered Do you pull double trailers? Yes No Triple trailers? Yes No
12. Do you operate over a regular route?
Yes No If yes, show towns operated between
13. List all types of cargo hauled
Principal Commodities Outbound Backhaul Commodities
14. Do you haul any hazardous or extra hazardous substances or materials as defined by EPA? Yes No
If yes, provide complete listing identifying all material(s) and/or chemical content
15. What percent of time are your vehicles operating under lease or dispatch?
16. Equipment is under permanent/long term lease to
17. How many companies have you been leased to in the last three years?
18. Do you lease to anyone else? Yes No If yes, percent of time %, for whom and explanation
19. Do you trip lease on back hauls to others? Yes No If yes, percent of time %, for whom and explanation
LIABILITY COVERAGE – Complete for desired coverages by indicating limits of insurance.
LIABILITY
Split Limits
Bodily Injury
Property
Damage
Combined Single
Limit BI & PD
Per Person Per Accident Per Accident
Medical
Payments
Personal
Injury
Protection
(where
applicable)
IF PHYSICAL DAMAGE COVERAGE
DESIRED, REFER TO FOLLOWING PAGE.
IF IN-TOW COVERAGE DESIRED,
COMPLETE TOW TRUCK SUPPLEMENT.
UNINSURED MOTORIST COVERAGE UNDERINSURED MOTORIST COVERAGE
Split Limits Split Limits
Bodily Injury Bodily Injury
Single Limit
Per Person Per Accident
Uninsured
Motorist
Stacking
Single Limit
Per Person Per Accident
Underinsured
Motorist
Stacking
Yes No Yes No
DRIVER INFORMATION – If additional space is needed, attach separate listing.
Driver's Licenses Experience
Driver's Name Date of Birth
State Number
Class/Type
(i.e. CDL)
Years
Licensed (in
class/type)
Type of Unit
(bus, van,
truck,
tractor, etc.)
No. of
Years
1.
2.
3.
4.
5.
M-5544 PA (12/2010) Contingent Liability Application Page 1 of 3
DRIVER INFORMATION (Continued) – If additional space is needed, attach separate listing.
Accidents and Minor Moving Traffic
Violations in Past 5 Years
Major Convictions
(DWI/DUI, hit & run, manslaughter, reckless,
driving while suspended/revoked, speed contest,
other felony)
No. Years
Previous
Commercial
Driving
Experience
Date of Hire
No. of
Accidents
Date(s)
No. of
Violations
Date(s) Describe Conviction Date(s)
Employee (E)
Ind. Cont. (IC)
Owner/Op. (O/O)
Franchisee (F)
1.
2.
3.
4.
5.
PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.
20. Are drivers covered by workers compensation?
Yes No If yes, name of carrier
21. Minimum years driving experience required Are vehicles owner-driven only? Yes No
22. Are drivers ever allowed to take vehicles home at night?
Yes No If yes, will family members drive? Yes No
23. Do you order MVRs on all drivers prior to hiring?
Yes No Driver's maximum driving hours daily weekly
24. Do you agree to report all newly hired operators?
Yes No
25. What is the basis for driver(s) pay?
Hourly Trip Mileage Other, explain
SCHEDULE OF AUTOS/VEHICLES – Describe all vehicles for which application is made for insurance.
Veh.
No.
Model
Year
Vehicle Make
& Model
Body Type (i.e.
truck, tractor,
trailer, etc.)
Full Vehicle Identification
Number
Gross
Vehicle
Weight
(GVW)
Total
# of
Rear
Axles
Principal Garaging
Location
(city & state)
Radius
of
Opera-
tion
Annual
Mileage
Per
Vehicle
(A) Anti-
Lock
Brakes,
(B) Air
Bags
1
2
3
4
5
26. Will lessor be added as additional insured? Yes No If yes, give name and address of lessor for each vehicle
27. Number of Vehicles Owned: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
28. Number of Vehicles Leased: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
PHYSICAL DAMAGE COVERAGE – Complete spaces below in detail for each respective auto/vehicle described above.
Physical Damage Deductible
Veh.
No.
Date
Purchased
Cost When
Purchased
Current Stated Value
(excluding permanently
attached equipment)
Value of Permanently
Attached Special
Equipment
Total Stated
Amount to be
Insured
Comprehensive
Spec. C of Loss
Collision
Cargo
Limit of
Insurance
1
2
3
4
5
29. Any loss payees? Yes No If yes, give name and address of mortgagee/loss payee for each vehicle
LOSS EXPERIENCE – Provide prior insurance carriers information for past full three years.
Policy Term Premium Total Amount Claims Paid & Reserves
From To
Insurance Company Name
No. of Motor
Powered
Vehicles
No. of
Accidents
Liab Phys Dam BI PD Comp/Coll Other
/ / / /
/ / / /
/ / / /
30. Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage
sought in this application?
Yes No If yes, provide complete details
31. Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No If yes, date and why
M-5544 PA (12/2010) Contingent Liability Application Page 2 of 3
MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the
policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is
acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may
not accept any funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false,
the Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be
attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that
endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the
Applicant or any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business
background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional
information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
Will premium be financed? Yes No If yes, with whom
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.
Witness Applicant's Signature Date
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE
Is this direct business to your office?
If not, explain
Is this new business to your office? If not, how long have you had the account?
How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Please quote Please bind at earliest possible date and issue policy
Please issue policy effective
Coverage was bound by
(Time and Date Bound by General Agent) (Name of Person in Company General Agency's Office Binding Coverage)
Applicant's Representative's Name and Address Phone No.
M-5544 PA (12/2010) Contingent Liability Application Page 3 of 3
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Application Contingent Liability (Bobtail & Deadhead) IndividualProprietorship Partnership (Risk Placement Services, Inc.)

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Completed 23 November 2020

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