Fillable Business Auto Questionnaire (Risk Placement Services, Inc.)

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Business Auto Questionnaire (Risk Placement Services, Inc.)

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Business Auto Questionnaire
U-GU-785-A CW (07/08)
Page 1 of 3
This questionnaire is to be completed in conjunction with Acord 125, 127 and a state specific form 137. Complete Acord 194 if a filing
is requested.
Applicant Name: Date Completed:
General Information
1. Percentage of trips of operation in the following radius categories:
0-50 % 101-200 % 301-500 %
51-100 % 201-300 % 500-over %
2. Has applicant ever operated under another name? Yes No
If yes, what was the name and authority number of that operation?
3. Percentage of loads:
% Over weight % Over width
% Over length % Over height
4. Does the applicant have Workers’ Compensation Insurance in place? Yes No
If yes, current carrier name:
5. Does the applicant allow non-employee passengers? Yes No
6. Does the applicant own / operate any mobile equipment? Yes No
If yes, describe:
7. Is any special equipment permanently attached to the power units or trailers?
Yes No
If yes, describe:
8. Does the applicant perform snow removal? Yes No
9. Are all vehicles licensed for road use? Yes No
If no, provide details:
10. Is there any personal use of scheduled autos?
Yes No
If yes, what % is the personal use? %
11. Do you allow your drivers to take autos home?
Yes No
If you answered yes to questions 10 or 11, are all potential drivers in the
household shown on the driver schedule?
Yes No
12. Number of vehicles insured:
Current Year 3
rd
Year Prior
1
st
Year Prior 4
th
Year Prior
2
nd
Year Prior
13. Is coverage for Audio, Visual and Data Electronic Equipment requested? Yes No
If yes, what limit per vehicle is needed (up to $10,000)?
14. Do you transport hazardous materials, waste or substance which requires placarding? Yes No
If yes, complete the Environmental Transport Questionnaire.
15. Does applicant travel to Mexico or Canada?
Yes No
If yes, provide details:
U-GU-785-A CW (07/08)
Page 2 of 3
Hired/NonOwned Auto
Complete only if Hired / Non-Owned Auto is requested.
Hired Auto Liability:
1. Does applicant subhaul, lease or hire equipment from others?
Yes No
If yes, provide the annual estimated cost of hire: Current year $ 2
nd
prior year $
1
st
prior year $ 3
rd
prior year $
If yes, is it: Permanently Leased Trip Leased
2. Is applicant named as additional insured? Yes No Limits required: $
3. If permanently leased, is it scheduled on this application? Yes No
4. If permanently leased, are autos hired with drivers?
Yes No
Hired Auto Physical Damage:
Does applicant rent or use substitute equipment?
Yes No
Non-Owned Auto:
1. Does applicant authorize personal auto use for business purposes?
Yes No
If yes, describe:
2. Does applicant require proof of insurance?
Yes No
3. What are the minimum limits required?
Broadened Pollution Endorsement:
Do you require Broadened Pollution Coverage? Yes No
Combined Deductible:
Is the applicant requesting a combined deductible?
Yes No
General Liability:
1. Is General Liability coverage in place?
Yes No
2. Do you want coverage for misdelivery of liquid products?
Yes No
3. What precautions are taken to assure that the proper liquid is unloaded into the proper tank?
4. Does applicant store or warehouse any commodities including but not limited to LPG, flammable liquids, chemicals etc.?
Yes No If yes, describe type, quantity and how stored:
5. Does applicant have any above-ground or under-ground storage tanks? Yes No
If yes, describe:
U-GU-785-A CW (07/08)
Page 3 of 3
Garbage Operations:
Complete only if garbage operation.
1. Percentage of garbage / trash / refuse hauled:
% Construction or debris collection container haulers
% Residential
% Commercial/Industrial
% Regulated Medical Waste or Biohazard Waste
% Salvage operations including scrap metal dealers
% Scrap metal for hire
% Transfer station to landfill
% Other – Please specify:
2. Type and number of vehicles:
Packer, Compactor
Rollback
Rolloff
Other – Please specify:
3. Please note that a minimum liability Property Damage deductible of $500 is required on this class.
If a higher Property Damage deductible is desired, please specify:
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Completed 30 July 2020

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