Fillable Application for Rental Autos & Trucks B Short (RT Specialty)

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Application for Rental Autos & Trucks B Short (RT Specialty)

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Application for Rental Autos
& Trucks B Short Term
(Hour, Day or Week)
Policy Term From:
To
1. Name of Applicant
2. a. Address of Applicant
(Number) (Street) (City) (County) (State) (Zip Code)
b. Address where vehicles are garaged if different than address of applicant
3. Applicant is: G Individual G Partnership G Corporation
4. Is this your primary business? G Yes G No If no, explain:
Years experience in this business?
5. Coverage to be effective from:
to:
6. Person to contact for inspection (name and phone number)
7. Is this a new operation? G Yes G No Is your operation currently for sale? G Yes G No Seasonal in nature? G Yes G No
8. Has this business ever operated under any other name? G Yes G No If yes, show previous name and address:
9. Give estimate of financial worth $
Gross receipts last year? Estimate for coming year?
10. Have you filed for bankruptcy within the last 5 years or do you contemplate doing so? G Yes G No If yes, provide details:
11. Have you under this name or any other name been insured with any of the above-listed companies? G Yes G No If yes, explain:
DESCRIPTION AND AREA OF OPERATIONS
12. Number of short term rental vehicles:
Private Passenger Autos
Pick-Ups Trucks Tractors Semi-trailers Trailers
Cargo Vans
Passenger Vans Others (specify)
13. Percentage of private passenger vehicles rented to: Personal?
% Military? % Commercial? %
Insurance Replacement?
%
14. Are any vehicles rented for 1 month or more? G Yes G No If yes, submit details (which units, to whom, term of rental or lease)
15. Are vehicles ever leased with drivers? G Yes G No If yes, attach complete list of drivers, vehicle(s) they drive, age of driver, license
number, and chargeable accidents during past three years.
16. Leasing Agreements: Attach copy of each type of rental or lease agreement used.
17. What is average term of rental?
days
18. What are your rules for selecting renters or lessees?
M-4128c VA (12/2007) Application for Rental Autos & Trucks - Short Term Page 1 of 5
Atlantic Specialty Lines, Inc.
9020 Stony Point Parkway
Suite 450
Richmond, VA 23235
Submit Application
(800)368-2095 FAX: (804)320-7280
19. What is minimum age of persons permitted to rent vehicles? Are additional drivers permitted? G Yes G No
If yes, how are they qualified?
20. Do you ask what the vehicle will be used for and where it will be driven? G Yes G No
21. Percent cash rental?
% Percent credit card? % If cash rental, how do you qualify renter?
22. Do you use an on-line service giving subscribers credit, driving & criminal history? G Yes G No If yes who?
23. Are written counter practice procedures furnished to all counter personnel? G Yes G No If yes, attach copy.
24. Are you named as additional insured on renter=s policy on any vehicles rented? G Yes G No Explain:
25. Do you require liability insurance from the rentee? G Yes G No Explain:
26. Do you obtain a certificate of liability insurance on any vehicles rented? G Yes G No Explain:
27. Do you rent or lease vehicles from others? G Yes G No If yes, explain:
28. Are any vehicles rented on a ARent It Here - Leave It There@ basis? G Yes G No
29. Is applicant required to file evidence of insurance with any state regulatory authority or any other authority? G Yes G No
If yes, specify:
30. Do you have your own repair shop? G Yes G No If yes, what kind of repairs are made?
31. Are rental contracts prenumbered? G Yes G No
32. How often are rental vehicles serviced?
COMPLETE QUESTIONS 33-36 FOR COMMERCIAL VEHICLES ONLY
33. Percentage of business derived from renting vehicles to individuals hauling their own personal goods or effects
%
Businesses
%
34. Are vehicles rented to trucking firms (truckers hauling for hire)? G Yes G No If yes,
%
35. Will you rent vehicles to be used to carry passengers for hire? G Yes G No
36. Are any vehicles rented to hazardous material haulers? G Yes G No If yes, explain:
PREVIOUS INSURANCE CARRIER AND LOSS EXPERIENCE
37. Provide prior insurance carriers information for past full three years. List in order with most recent carrier first.
Policy Term
Premium
Total Amount Claims Paid & Reserves
From
To
Insurance Company
Name
Policy
Number
Number
of Motor
Powered
Vehicles
Number
of
Accidents
Liab
Phys
Dam
BI
PD
Coll
Other
/ /
/ /
/ /
/ /
/ /
/ /
38. Have you ever been declined, canceled or nonrenewed for this kind of insurance? G Yes G No If yes, date and why
39. 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? G Yes G No If yes, provide complete details
Application for Rental Autos & Trucks - Short Term Page 2 of 5
V V
INSURANCE NEEDS & SCHEDULE OF VEHICLES
40. COMPLETE FOR DESIRED COVERAGES BY INDICATING LIMITS OF INSURANCE
Liability
Uninsured Motorists
Underinsured Motorists
Split Limits
Split Limits
Split Limits
Physical
Damage
Bodily Injury
Property
Damage
Combined
Single
Limit
BI & PD
Each
Person
Each
Accident
Each
Accident
Single
Limit Each
Accident
Each
Person
Each
Accident
Single
Limit Each
Accident
Each
Person
Each
Accident
Medical
Payments
Personal
Injury
Protection
Complete
section
below if
wanted
41. Liability limits for rentee: BI each person $ BI each accident $
PD each accident $
Or combined single limit BI & PD $
42. SCHEDULE OF AUTOS/VEHICLES TO BE COVERED (If more than 8, attach additional schedule with information below)
Auto
No.
Year
Model
Trade Name
Body Type**
Serial No. (S)
Vehicle ID No. (VIN)
Anti-
Theft
Devices
Yes
or No
Air-
bags
Yes
or No
Licensed
Weight*
Anti-
Lock
Brakes
Yes
or No
Lift or
Lift
Gate
Yes
or No
Dual
Rear
Axles
Yes
or No
Estimated
Annual
Mileage
Maximum
Radius of
Operations
(miles)
1
2
3
4
5
6
7
8
*Licensed Weight B Gross Vehicle Weight (GVW) weight of vehicle and load or Gross Combined Weight (GCW) weight of vehicles and load.
**Body Type: PPT Priv. Pass. Type PIC UP Pick Up TNK TK Tank Truck FLT TR Flat Trailer Other (Specify)
JEEP Jeep BOM TK Boom Truck OTH TK Other Truck STK TR Stock Trailer
PSS VN Pass. Van CRN TK Crane/Truck TRACT Tractor TNK TR Tank Trailer
CRG VN Cargo Van DMP TK Dump Truck BX TR Box Trailer UTL TR Utility Trailer
COMPLETE THESE SPACES ONLY IF PHYSICAL DAMAGE COVERAGE DESIRED
Specified Causes of
Loss
Collision
Auto
No.
Town & State Where
Principally Garaged
Use*
Original
Cost New of
Chassis,
Body &
Equipment
Date
Purchased
Mo/Yr
Cost
When
Purchased
Value of
Vehicle
Excluding
Permanently
Attached
Special
Equipment
Value of
Permanently
Attached
Special
Equipment
Amount of
Insurance
Deductible
Amount of
Insurance
Deductible
1
2
3
4
5
6
7
8
* Enter one or more of the following initials to indicate use of each auto.
RI B Rented to Individuals RT B Rented to Truckers ST B Non-Rental Business Service Truck
RB B Rented to Businesses BA B Non-Rental Business Auto O B Other (describe)
43. ANY LOSS PAYEES? G Yes G No If yes, indicate for which vehicle(s) and give name and address of loss payees:
Application for Rental Autos & Trucks - Short Term Page 3 of 5
SELECTION OF LIMITS FOR UNINSURED/UNDERINSURED MOTORISTS COVERAGE
(Virginia)
Virginia Insurance Code Section 38.2-2206 provides that policies of insurance which provide bodily injury or property damage
liability insurance relating to the ownership, maintenance or use of a motor vehicle issued or delivered in the Commonwealth of
Virginia must provide Uninsured motor vehicle coverage in limits not less than $25,000 because of bodily injury to or death of one
person in any one accident and $50,000 because of bodily injury to or death of two or more persons in any one accident, and
$20,000 because of injury to or destruction of property of others in any one accident. Such policies must also provide coverage for
bodily injury or property damage caused by the operation or use of an Underinsured motor vehicle.
Under Virginia law, the limits of Uninsured/Underinsured motorist coverage must equal the limits of the liability insurance provided
by your policy unless additional coverage is rejected by any one named insured. Therefore, if you purchase liability insurance in
amounts greater than the state mandated minimum limits of $25,000/50,000/20,000, your Uninsured/Underinsured motorist
coverage limits will equal these greater limits.
If you purchase liability insurance limits in excess of $25,000/50,000/20,000 you may reject the increased limits of
Uninsured/Underinsured motorist coverage. If you reject the increased limits of Uninsured/Underinsured motorist coverage you
must at a minimum purchase the state-mandated limits of $25,000/50,000/20,000. You may also choose to purchase
Uninsured/Underinsured motorist coverage limits in excess of the state-mandated minimum amount yet less than your liability
insurance limits. Ask your producer for coverage limits offered.
The rejection of the additional limits of Uninsured/Underinsured motorist insurance by any one named insured is binding on all
insureds under such policy.
In accordance with the Virginia law, the undersigned insured (and each of them):
(Applicable item marked 7)
Selects Uninsured/Underinsured motor vehicle coverage limits in the amount of $25,000/50,000/20,000. These are the lowest
coverage limits which may be purchased by law.
Selects Uninsured/Underinsured motor vehicle coverage limits which are lower than the liability limits under the policy but
higher than the state-mandated minimum limits. Selected limits for Uninsured/Underinsured motorist coverage are:
(Enter limits if a separate limit of liability applies)
$
Bodily Injury each person
$
Bodily Injury each accident
$
Property Damage each accident
(Enter limit if a single limit of liability applies)
$
Each accident
MEDICAL EXPENSE AND INCOME LOSS BENEFITS SELECTION
Medical Expense Benefits
- Choose one:
G Reject
G Accept If accepting, choose one: G $500 G $1000 G $2000 G $5000
Income Loss Benefits
- Choose one:
G Reject
G Accept
I have indicated my choice above ("X" indicates my choice):
Signature of Insured Signature of Insured
Date Policy Number
(Until you advise us otherwise in writing, your choices, as indicated above, will continue regardless of any addition or change
in Auto coverage on your current policy or addition of any Scheduled Autos.)
SIGNATURE IS ALSO REQUIRED ON LAST PAGE OF APPLICATION
Application for Rental Autos & Trucks - Short Term Page 4 of 5
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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 Interstate Commerce Commission requires a special endorsement to be
attached to the policy which increases 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? G Yes G No If yes, with whom
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND
DENIAL OF INSURANCE BENEFITS.
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:
G Please quote
G Please bind at earliest possible date and issue policy
G Please issue policy effective
Coverage was bound by
(Time and Date Bound by General Agent) (Name of Person in Company General Agent's Office Binding Coverage)
Applicant's Representative's Name and Address Phone No.
Application for Rental Autos & Trucks - Short Term Page 5 of 5
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Application for Rental Autos & Trucks B Short (RT Specialty)

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Completed 13 December 2020

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