Fillable Excess Auto Supplement (Risk Placement Services, Inc.)

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Excess Auto Supplement (Risk Placement Services, Inc.)

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Excess Auto Supplement
COLUMBIA INSURAN
CE 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:
This application supplement is for an excess auto policy providing additional limits of liability coverage for bodily injury,
property damage, or covered pollution cost or expense and will not provide any other types of coverage.
The excess auto policy will not provide uninsured motorists coverage, underinsured motorists coverage, no-fault
coverage, medical payments coverage, first party personal injury protection coverage, garagekeepers legal liability
coverage, physical damage coverage, auto in-tow coverage, first party property damage protection coverage or any other
coverage similar to the foregoing, regardless of whether such coverage is provided by the "Primary Insurance".
This Supplement is a part of the Application and will be relied upon by the Company as an integral part of the Application.
COVERAGE INFORMATION
Total Policy Liability Limits Requested (primary and excess combined)
Will the primary policy be written with one of the above listed companies?
Yes No
Do you require coverage on the excess policy that differs from the primary policy?
Yes No
If yes, explain _______________________________________________________________________________
Will all autos owned or operated be covered by the primary policy?
Yes No
If no, explain ________________________________________________________________________________
Do you require all covered autos on the primary policy also to be covered autos on the excess policy?
Yes No If no, explain _________________________________________________________
__________________________________________________________________________________________
Primary Garaging Location(s) __________________________________________________________________
__________________________________________________________________________________________
FILING INFORMATION
Is an FHWA filing required? Yes No If yes, MC number______________________________
Common Contract Broker Do you require FHWA cargo filing?
Yes
No
If you hold a broker’s license, identify name filed with FHWA, FHWA docket # and receipts from brokerage operations
If you are an interstate regulated carrier, identify your registration or base state ___________________________
Is an intrastate filing needed?
Yes No If yes, show state and permit number __________________
__________________________________________________________________________________________
Show exact name and address in which permits are issued ___________________________________________
__________________________________________________________________________________________
M-5555 (12/2010) Excess Auto Supplement Page 1 of 2
Is an MCS 90 endorsement needed? Yes No
Are the primary and excess policies to cover all vehicles owned, operated or under lease to applicant?
Yes No If no, explain _________________________________________________________
Are oversize/overweight commodities hauled?
Yes No If filing required, show states __________
__________________________________________________________________________________________
Does your authority allow for transportation of hazardous commodities?
Yes No
Do you allow others to haul hazardous commodities under your authority? Yes No
Have you ever changed your operating name? Yes No
Do you operate under any other name? Yes No
Do you enter Canada? Yes No
Do you enter Mexico? Yes No
Do you operate as a subsidiary of another company? Yes No
Do you own or manage any other transportation operations that are not covered? Yes No
Do you lease your authority? Yes No
Do you appoint agents or hire independent contractors to operate on your behalf? Yes No
Have you purchased, sold or applied for authority over the past 3 years? Yes No
Have you ever lost or had authority withdrawn or have you been/are
under probation by any regulatory authority (FHWA, PUC, etc.)? Yes No
Is evidence/certificate(s) of coverage required? Yes No
Please explain any "yes" answer to these questions _________________________________________________
__________________________________________________________________________________________
I acknowledge that I have read this application supplement and understand that:
THIS APPLICATION SUPPLEMENT IS FOR AN EXCESS AUTO POLICY PROVIDING ADDITIONAL LIMITS OF LIABILITY
COVERAGE FOR BODILY INJURY, PROPERTY DAMAGE, OR COVERED POLLUTION COST OR EXPENSE AND WILL NOT
PROVIDE ANY OTHER TYPES OF COVERAGE.
MY PRIMARY AUTO LIABILITY INSURANCE POLICY PROVIDES AT LEAST THE AMOUNT OF UNINSURED OR
UNDERINSURED MOTORIST (UM/UIM) COVERAGE WHICH LEGALLY IS REQUIRED.
THIS EXCESS AUTO POLICY DOES NOT PROVIDE ANY UNINSURED OR UNDERINSURED MOTORIST (UM/UIM)
COVERAGE.
Completed by the Insured ______________________________________ Date ________________________
Insured’s Signature
M-5555 (12/2010) Excess Auto Supplement Page 2 of 2
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Excess Auto Supplement (Risk Placement Services, Inc.)

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Completed 30 July 2020

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