Auto Renewal Questionnaire
COLUMBIA INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY OF THE SOUTH
NATIONAL INDEMNITY COMPANY OF MID-AMERICA
Policy Term From:
To:
Named Insured Policy No.
Renewal Date
1. Complete the following: Have there been any changes - if yes, explain.
Yes No
(a) Named Insured
(b) Address of Insured
(c) Largest City Entered
(d) Maximum Radius Operated
(e) No. of Vehicles Owned
(f) No. of Vehicles Leased
(g) Are all owned & leased vehicles covered under this policy? Yes No If no, explain
2. Is there any change in operations? Yes No If yes, explain
3. Indicate any changes in units or coverages to be made at renewal
4. For Public Vehicles: Is your operation For Profit Non-Profit
5. If insured is leased out, to whom is he currently leased?
6. Do you presently have or are you applying for a permit(s) for transportation of hazardous material and/or radioactive materials?
7. Is there any change in types of commodities hauled? Yes No If yes, explain
8. Person to contact for inspection (name and phone number)
9. Have you ever filed or are you contemplating filing for reorganization or bankruptcy? Yes No If yes, show date (month and
year) and explain: ____________________________________
______________________________________________________________________________________________________
10. MUST BE COMPLETED FOR ALL DRIVERS (if not enough space attach list)
Driver’s Licenses Experience
Driver's Name
Date of
Hire
Date of
Birth
State Number
No. of
Years
Licensed
Type of Unit
(bus, van,
etc.)
No. of
Years
1.
2.
3.
4.
5.
11. When physical damage provided, indicate current depreciated value(s)
12. Any accidents or violations in the past twelve (12) months? Yes No If yes, explain
13. Are DOT filings required? Yes No If yes, list MC number and required filings
Are state filings required? Yes No If yes, identify all states/filings/ID numbers
14. Are there any changes to loss payees? Yes No If yes, explain
The Applicant's representative acknowledges that he/she has advised the Insured and the Insured agrees that if the foregoing statements and
answers are materially false, the Company shall have the right to rescind any policy it may issue or any renewal thereof. All terms, conditions, and
applicable endorsements of the previous policy shall apply. Representations made on the Insured’s original Company application shall survive
renewal unless modified by this document.
Date
Applicant's Representative
Address of Applicant's Representative
M-5552 (12/2010) Auto Renewal Questionnaire Page 1 of 1
