Fillable Hired & Non-Owned Auto Supplement (RT Specialty)

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Hired & Non-Owned Auto Supplement (RT Specialty)

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Hired & Non-Owned Auto
Supplement
Policy Term From: To
This Supplement is a part of the Application and will be relied upon by the Company as an integral
part of the Application. Notify premium finance company of hired auto audit requirements.
HIRED AUTO COVERAGE
1. Number of autos (as defined in the policy) to be scheduled on the policy:
2. Gross receipts: Past Year $ Estimate for Coming Year $
3. Type of operation (give description of operation):
4. Type of policy: G Commercial Auto G Trucker G Public
5. Annual cost incurred for hired autos: $ . Is the insured involved in any
arrangements for the borrowing or bartering for the use of autos? G Yes G No
If yes, explain:
6. Does any agent, independent contractor, or employee lease autos in the Insured's name? G Yes G No
If yes, explain:
7. Does the insured utilize owner/operators, independent contractors, or subcontractors? G Yes G No
If yes, how many? ? Are they under permanent lease to the insured? G Yes G No
Are they shown as scheduled autos on your application? G Yes G No
If no, is their cost included in the estimated cost of hired autos in question 5 above? G Yes G No
8. Types of autos hired:
What is gross vehicle weight of commercial autos?
What is passenger capacity of public autos?
9. What is the average term of lease?
10. Are the same autos leased or does it vary? G Same Autos G Varies
11. If the same, explain why the autos cannot be scheduled on the policy.
12. What percentage of the hired autos' revenue is paid to owners of the hired autos? %
13. Are drivers to be provided by the insured to operate hired autos? G Yes G No
If no, will the drivers be required to provide Certificates of Insurance? G Yes G No
What are the minimum liability limits required by the lessee (named insured)?
14. Will the insured be named as an additional insured on the lessor's policy? G Yes G No
15. Does the insured lease, hire, rent or borrow any auto, other than a private passenger type
auto, owned or leased by the insured's employees, partners or members of their household? G Yes G No
If yes, give details and how many.
4055c VA (11/2003) Hired & Non-Owned Auto Supplement Page 1 of 2
Atlantic Specialty Lines, Inc.
9020 Stony Point Parkway
Submit Application
Suite 450
Richmond, VA 23235
(800)368-2095 FAX: (804)320-7280
16. Does the insured own or control any subsidiary or is it affiliated with any other corporation? G Yes G No
If yes, are vehicles leased from that subsidiary or affiliate? G Yes G No
17. What is the business of the subsidiary or affiliate?
18. Are ICC or state regulatory filings required? G Yes G No
19. Does the insured have an ICC broker's authority or provide a brokerage service? G Yes G No
20. Does the insured understand that we intend to audit his records regarding the cost of hire? G Yes G No
21. Is the premium financed? G Yes G No
NON-OWNED AUTO COVERAGE – This coverage not available unless written with primary auto liability including hired auto coverage
1. Why is non-ownership liability coverage being requested?
2. What types of non-owned autos will be used in the insured's business?
How will they be used?
3. What is the maximum distance which a non-owned auto may be driven from the insured's
premises? miles.
4. Total number of non-owned autos used in the insured's business?
5. Total number of employees?
6. If a social service operation, indicate total number of volunteers furnishing autos in the insured's
operation. Maximum number of volunteers at any one time.
7. How often are non-owned autos used in the insured's business? G Daily G Weekly G Monthly
Estimate number of hours used per month.
8. Do your employees lease autos on insured's behalf? G Yes G No
If yes, under whose name are autos leased? G Employees G Insured
9. What is the estimated annual mileage for use of all non-owned autos?
miles.
10. Do you require employees to have their own insurance? G Yes G No
If yes, what are the minimum limits required?
Do you require evidence of insurance? G Yes G No
11. Will you use non-owned autos other than those owned by your employees? G Yes G No
If yes, describe relationship.
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES
AND DENIAL OF INSURANCE BENEFITS.
Completed by insured Date
(Insured's Signature)
Hired & Non-Owned Auto Supplement Page 2 of 2
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Hired & Non-Owned Auto Supplement (RT Specialty)

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Completed 13 December 2020

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