Fillable Hired & Non-Owned Auto Supplement This Supplement is (Risk Placement Services, Inc.)

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Hired & Non-Owned Auto Supplement This Supplement is (Risk Placement Services, Inc.)

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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: Commercial Auto Trucker 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? Yes No
If yes, explain:
6. Does any agent, independent contractor, or employee lease autos in the insured's name? Yes No
If yes, explain:
7. Does the insured utilize owner/operators, independent contractors, or subcontractors? Yes No
If yes, how many?
? Are they under permanent lease to the insured? Yes No
Are they shown as scheduled autos on your application? Yes No
If no, is their cost included in the estimated cost of hired autos in Question 5 above? Yes 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? Same Autos 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? Yes No
If no, will the drivers be required to provide Certificates of Insurance? Yes 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? Yes 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? Yes No
If yes, give details and how many.
M-5553 VA (12/2010) Hired & Non-Owned Auto Supplement Page 1 of 2
16. Does the insured own or control any subsidiary or is it affiliated with any other corporation? Yes No
If yes, are vehicles leased from that subsidiary or affiliate? Yes No
17. What is the business of the subsidiary or affiliate?
18. Are ICC or state regulatory filings required? Yes No
19. Does the insured have an ICC broker's authority or provide a brokerage service? Yes No
20. Does the insured understand that we intend to audit his records regarding the cost of hire? Yes No
21. Is the premium financed? Yes 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? Daily Weekly Monthly
Estimate number of hours used per month.
8. Do your employees lease autos on insured's behalf? Yes No
If yes, under whose name are autos leased? Employees 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? Yes No
If yes, what are the minimum limits required?
Do you require evidence of insurance? Yes No
11. Will you use non-owned autos other than those owned by your employees? Yes 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)
M-5553 VA (12/2010) Hired & Non-Owned Auto Supplement Page 2 of 2
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Completed 30 July 2020

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