NIPC SS Non Owned Auto Supp (01/08) rev. 10/14 1
NON-OWNED AUTO QUESTIONNAIRE
RISK NAME: _______________________________________________ Address:_______________________________________________________
HIRED AUTO:
1. For what purpose do you require hired
autos?
2. Average number of hired autos rented/leased annually:
3. Types of autos rented/leased:
4. Total Number of Employees:
5. Average Term of Lease/rental agreement:
6. Estimated Cost of hired autos for this year:
7. Minimum liability limits required:
NON OWNED AUTO:
8. Do you have existing Auto coverage with another carrier?
Yes No
9. Do you require minimum limits of liability of $100,000 for any employee or volunteer that drives their vehicle on your behalf?
Yes
No
10. We require minimum limits of liability of $100,000 for any employee or volunteer that drives their vehicle on your behalf. Will you
implement this requirement into your management practice?
Yes No
11. Do you obtain a copy of their Declarations Page or Certificate of Insurance and update it annually?
Yes No
12. Total number of employees:
13. Total number of non-owned autos used in your business:
14. Will non-owned autos other than private passenger types, pickups or vans be used? Yes No
If yes, please describe autos and how they will be used:
15. Are clients transported? Yes No
16. Are non-owned autos likely to be operated beyond 50 miles?
Yes No
If yes, how often and why?
17. Indicate the total number of volunteers furnishing autos for your operation:
Maximum number of volunteers at one time:
18. How often are non-owned autos used in your business? Daily Weekly Monthly
19. Do you report employee mileage for tax purposes?
Yes No
If yes, how many miles were reported last year?
20. It is management’s responsibility to establish and enforce driver selection criteria. Do you order MVR’s annually for all employees
and volunteers driving their own vehicles on your behalf?
Yes No
21. Please describe your procedure for evaluating MVR’s to identify unacceptable or marginal drivers:
_________________________________________________________________________________________________________
_________________________________________________________________
22. Have you had any non-owned auto losses in the past five years?
Yes No
(If yes, please attach current loss runs.)
____________________________ ____________________________
Date Signed Signature of Applicant
____________________________
Name and Title
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signature
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