- HIRED AND NON-OWNED AUTO LIABILITY
SUPPLEMENTAL APPLICATION
SECTION I – NON-OWNED AUTO LIABILITY
Number of employees using their own vehicles for company business on a regular or full time
basis:
Number of employees using their own vehicles for company business on an occasional or
infrequent basis:
What type of activities are the employees performing when they drive their own vehicle on
company business?
For those employees who use their own vehicles for company business, does the Applicant require
the employee to carry at least the minimum primary limits required by law in that state?
Does the Applicant have a system to verify that the employees have their own insurance at
acceptable limits?
SECTION II – HIRED AUTOMOBILE LIABILITY
How many vehicles are rented or leased each year?
For what purpose are the rented or leased vehicles used?
What is the estimated total annual cost for all leased or rented vehicles? $
What is the average length for the lease for these vehicles?
This application is to be used in conjunction with a completed E-PAC Primary Application.
The Undersigned states that
he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable
inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete
and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to
the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
_________________________________________________
APPLICANT: (Signature of Owner or Officer of Corporation)
APPLICANT: (Print/Type Name and Title)
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© 2019 Philadelphia Consolidated Holding Corp.
