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KINSALE HNO Supplemental - KINSALE_HNO_Supplemental1

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KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page1of3



ENERGYDIVISION

HIREDANDNON‐OWNEDSUPPLEMENTAL

APPLICATION

COMPLETEINADDITIONTOACORDAPPLICATIONS.

ATTACHADDITIONALSHEETSASNECESSARY.

ATTACHCOPIESOFANYANDALLLEASE,RENTAL,OROTHERAUTO‐RELATEDAGREEMENTS.

ANSWERALLQUESTIONS.Ifnotapplicable,indicateN/A.



1. NamedInsured: 

2. MailingAddress:  

3. State/areaofoperation: 

4. Whichcoverage(s)isbeingrequestedbyinsured? Hiredauto Non‐ownedauto Both



ATION

5. Isacommercialautomobilepolicyineffect? Yes No 

6. Whydoestheinsuredneedthiscoverage? 

7. Whataretheagerestrictionsfordrivers?______________________________________________________________

8. Howwillthefollowingnon‐owned/rentedvehiclesbeused?

a. Privatepassenger:______________________________________________________________________

b. Pick‐ups/vans:_________________________________________________________________________

c. Lighttrucks:___________________________________________________________________________

d. MediumTrucks:________________________________________________________________________

e. HeavyTrucks:_________________________________________________________________________

f. ExtraHeavyTrucks:_____________________________________________________________________

g. Tractors:______________________________________________________________________________

h. ExtraHeavy

Tractors:____________________________________________________________________





9. Istherewrittencompanypolicyrequiringemployeesusingpersonalvehiclesforbusinesspurposes

tocarrypersonalautoliabilityinsurance? Yes

No 

NAMEDINSUREDINFORMATION

GENERALINFORMATION

NON‐OWNEDAUTO

Page2of3



10. Howmanyemployeeswillbedrivingpersonalvehiclesforbusinesspurposes? 

11. Willanynon‐ownedvehiclesbeusedforbusinesspurposes,otherthanthoseownedbyemployees? Yes No 

12. Doyourequireemployeestocarryminimumlimitsofinsuranceontheirpersonalauto

liabilityinsurancepolicies? Yes

No 

a. Ifyes,whatlimitsarerequired?______________________________________________________________

13. Howfrequentlywillinsuredusenon‐ownedautos?Daily

Weekly Monthly 



ERAL



14. Whatistheannualcostofhire?  

15. Howmanyvehicleswillbeleased/rentedforupcomingpolicyperiod?_________________________________________

16. Pleaseprovidecostofhireforexpiringpolicyperiod:_______________________________________________________

17. Pleaseprovidenumberofvehiclesleased/rentedduringexpiringpolicyterm:___________________________________

18. Howfrequentlywillinsuredusehireauto?Daily

Weekly Monthly 

19. Areanyvehiclesrented,hired,orleasedfromemployeesoftheinsuredforusedbyotheremployees? Yes

No 

a. Ifyes,pleaseelaborate:_____________________________________________________________________

20. Areanypoliciesinplaceinrelationtoborrowingorlendingofemployees’vehiclestootheremployees? Yes

No 

a. Ifyes,pleaseelaborate:_____________________________________________________________________



FRAUDWARNING

NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE , GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,

MARYLAND,MASSACHUSETTS, MICHIGAN,MINNESOTA, MISSISSIPPI,MISSOURI,MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTHCAROLINA,

NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTHDAKOTA, TEXAS, UTAH,VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,

AND WYOMING APPLICANTS:In some states, any person who knowingly, and with intent to defraud an y insurance company or other person, files an

applicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation,or,forthepurposeofmisleading,concealsinformationconcerning

anyfactmaterialthereto,maycommita

fraudulentinsuranceactwhichisacrimeinmanystates.

NOTICETOCOLORADOAPPLICANTS:Itisunlawfultoknowinglyprovidefalse,incompleteormisleadingfacts orinformation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policyholderorclaimingwithregardtoasettlementorawardpayableforinsuranceproceeds

shallbereportedtotheColoradoDivisionofInsurance

withintheDepartmentofRegulatoryAgencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:WARNING: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insurancecompanyfilesastatementof claim

containinganyfalse,incompleteormisleadinginformationisguiltyofafelonyofthethirddegree.

NOTICE TO HAWAII APPLICANTS: 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 KENTUCKY APPLICANTS: Anyperson whoknowinglyandwith intent to defraud any insurance companyorotherperson files an application for

insurance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.

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subjecttofinesandconfinementinprison.

HIREDAUTO

Page3of3



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denialofinsurancebenefits.

NOTICE TO NEW JERSEY APPLICANTS: Anyperson whoincludes any false or misleading information on an application for an insurance policy is subject to

criminalandcivilpenalties.

NOTICETONEWMEXICO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civilfinesandcriminalpenalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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fraudule nt

insuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalueof

theclaimforeachsuchviolation.

NOTICETOOHIOAPPLICANTS:Anypersonwho,withintenttodefraudorknowingthathe/sheisfacilitatingafraudagainstaninsurer,submitsanapplication

orfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.

NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesaanyclaimfor

theproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

NOTICETOPENNSYLVANIAAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompany,orotherperson,filesanapplication

for insurance or statement of a 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thepersontocriminalandcivilpenalties.

NOTICE TOTENNESSEE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includeimprisonment,finesanddenialofinsurancebenefits.

NOTICETOVIRGINIA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includeimprisonment,finesanddenialofinsurancebenefits.

TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthattheabove

statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omitany

materialfacts.

TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffectivedate

ofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdrawnbased

uponsuch

changesatoursolediscretion.

Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy

issuance.

All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this

applicationandmadeapartofthisapplication.

Applicant:______________________________________ Title:  

 (MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)



FEIN#:     



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KINSALE HNO Supplemental - KINSALE_HNO_Supplemental1

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Completed 2 July 2020

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