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HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION 1-800-423-7675 Fax (Risk Placement Services, Inc.)

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CA-APP-12 (1-13) Page 1 of 4
HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION
1-800-423-7675 • Fax (480) 483-6752
Name of Applicant:
D/B/A:
Street Address:
P.O. Mailing Address:
Phone Number: ( )
FEIN/Social Security/Soundex No.:
Website:
Agent Name:
Address:
Agent No.:
PROPOSED EFFECTIVE DATE:
From
To
12:01 A.M., Standard Time, at the address of the Applicant.
PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
HIRED AUTO INFORMATION—Coverage Subject to Audit
1. Why is hired auto coverage being requested?
2. Do you lease, hire, rent or borrow any vehicles from others? ............................................................. Yes No
What is the average term of the lease?
Is there a written agreement? ...................................................................................................................... Yes No
Does it include a Hold Harmless agreement and/or Additional Insured clause? ........................................
Yes No
Provide a copy of the agreement.
3. Do you hire independent contractors? ...................................................................................................
Yes No
If yes, do you require certificates of insurance? ..........................................................................................
Yes No
Provide a copy of the contract.
4. If owner/operators are leased, will they be scheduled on your policy? .................................................
Yes No
If yes, provide a copy of the agreement you use.
5. Do you use sub-haulers? ..........................................................................................................................
Yes No
If yes, provide cost of hire. .................................................................................................................... $
Provide a copy of the contract.
6. Do you lease, hire, rent, or borrow any vehicles from others without drivers? .................................
Yes No
Will they be scheduled on the policy? .........................................................................................................
Yes No
What is the average term of the lease?
7. What is your cost to lease, hire, rent or borrow vehicles?
National Casualty Company
Home Office: Madison, Wisconsin
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
CA-APP-12 (1-13) Page 2 of 4
With drivers: .................................... Without drivers: .........................................
Estimated cost of hired autos:
This year: ........................................
Last year: ...................................................
8. Is Hired Auto Physical Damage coverage desired? ............................................................................... Yes No
If yes, average value of auto hired?
9. How many autos are hired on average within a twelve (12) month period?
10. How many hired autos are in the insured’s possession at any one time?
11. What type of vehicles do you lease, hire, rent or borrow? Truck-Tractors % Trailers %
Heavy & Extra Trucks % Pickup trucks or Vans % Private Passenger Cars %
12. At any time will your employees, subcontractors, or owner/operators lease vehicles in your
name? .........................................................................................................................................................
Yes No
If yes, explain:
13. Do you arrange or dispatch loads for others, not including your own hired truckers? .................... Yes No
Please explain:
Are you named on the Bills of Lading? ........................................................................................................ Yes No
Annual number of Truckers:
Loads:
14. Do you have motor carrier brokerage authority? ................................................................................... Yes No
If yes, is the brokerage authority held under the same name and motor carrier number as your trucking
operation? ....................................................................................................................................................
Yes No
What is your motor carrier brokerage number?
Whose name appears on the Bill of Lading as the carrier?
What is your brokerage revenue for the most recent twelve (12) months?
Estimated next twelve (12) months?
15. Do you understand that we may audit your records for Hired auto exposure, which might result
in an additional premium? ........................................................................................................................
Yes No
NON-OWNED AUTO INFORMATION—Coverage Subject to Audit
16. Why is non-ownership liability coverage being requested?
17. What types of non-owned autos will be used in your business?
Total number of non-owned autos used: ......................................................................................................
How will they be used?
18. How often are non-owned autos used in your business?
Daily Weekly Monthly Other:
Estimate the number of hours per month:
Estimated annual mileage for use of all non-owned autos:
19. Do any employees use their autos in your business? .......................................................................... Yes No
If yes, what limit of liability insurance are they required to maintain?
Do you require evidence of insurance? ....................................................................................................... Yes No
20. Will you use non-owned autos other than those owned by employees? ............................................ Yes No
If yes, describe the relationship:
21. Total number of employees: Total number of officers and partners:
CA-APP-12 (1-13) Page 3 of 4
22. If a social service operation, indicate the total number of volunteers furnishing autos in your
operation: ....................................................................................................................................................
Maximum number of volunteers at any one time: ........................................................................................
How will they use their vehicles?
23. Are volunteers required to have their own insurance? .........................................................................
Yes No
Minimum limits required:
24. Do you obtain motor vehicle records for all employees and volunteers? .......................................... Yes No
25. Do you understand that we may audit your records for Non-Owned auto exposure, which might
result in an additional premium? .............................................................................................................
Yes No
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable to Nebraska, Oregon or Vermont).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a
fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
CA-APP-12 (1-13) Page 4 of 4
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
Note to General Agent: If hired auto coverage is provided, notify the Premium Finance Company of the audit required.
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HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION 1-800-423-7675 Fax (Risk Placement Services, Inc.)

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Completed 30 July 2020

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