PUBLIC AUTO APPLICATION SUPPLEMENT
HIRED AUTO - PHYSICAL DAMAGE COVERAGE
Name
Submission/Policy Number:
Proposed Effective Dates: FROM:
TO:
Yes
No
N-3424 (6/14)
Applicant's Signature
Date
© 2014 The Travelers Indemnity Company. All rights reserved.
Yes
No
Yes
No
Yes
No
1.
Does Named Insured/applicant carry Physical Damage coverage on their owned vehicles?
2.
Maximum value of the leased vehicle(s): $
3.
Estimated number of days:
4.
Deductibles:
Collision:
$100 $250 $500
$1,000 $2,500
Comprehensive/SCL:
$100 $250 $500
$1,000
$2,500
Binding of Coverage is Subject to Compliance with Underwriting Authority
5.
Does the Named Insured/applicant have a proven accounting and recordkeeping system that is readily available to
Northland Insurance that conforms to terms and conditions of this coverage?
6.
Does the Named Insured/applicant keep records of all units added for Hired Auto Physical Damage coverage and the
number of days each unit was covered?
7.
Does the Named Insured/applicant require written rent/lease contracts between the insured and equipment owners for
all transactions prior to the transactions taking place?
Requirements
Hired Auto Physical Damage coverage is subject to a minimum daily rate that is fully earned.
The Named Insured will supply a report to the company within 15 days of the end of the policy term showing the number of
vehicles and the number of days per vehicle that it was insured.
The Named Insured agrees to pay any additional premium due the company for additional coverage provided.
Coverage is Subject to Audit
I certify and represent that the above responses are full and true statements and are provided as part of my application for
insurance coverage.
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