Fillable PUBLIC AUTO APPLICATION (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank PUBLIC AUTO APPLICATION (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PUBLIC AUTO APPLICATION (Risk Placement Services, Inc.)

On average this form takes 133 minutes to complete

The PUBLIC AUTO APPLICATION (Risk Placement Services, Inc.) form is 8 pages long and contains:

  • 2 signatures
  • 197 check-boxes
  • 433 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PUBLIC AUTO APPLICATION
Entire Application Must Be Completed and Signed
GENERAL INFORMATION
Name
Individual
Corporation
Partnership
LLC
Other:
Submission Number:
Proposed Effective Dates: FROM:
TO:
Mailing Address
City
State
ZIP Code
Business Phone
E-Mail Address
Garaging Address
City
State
ZIP Code
(if different)
OWNER/PRINCIPAL
Owner Name (First, Middle, Last)
Home Address
City
State
ZIP Code
Business Phone
SS # of Owner
Apt. #
Tax ID: Federal ID # or SS #
U.S. DOT #
Yrs. Applicant has been Operating Under Business Name
Safety Contact Person Name
Contact's Phone
Safety E-Mail Address
MC #
DESCRIPTION OF OPERATIONS
For Hire
Private
Other:
Type of Operation:
Check type(s) of operations:
Commodity (Check any that apply)
Commodity
Hazardous Materials requiring $1,000,000 Liability limits or less
Hazardous Materials requiring Liability limits higher than $1,000,000.
% of Loads
Max. Value
Commodity
% of Loads
Max. Value
Explain:
For Profit
Airport Bus
Airport Limo
Airport Taxi (internal)
Ambulance (internal)
Athletes & Entertainers
Casino Gambling Bus
Charter Bus
Charter Bus w/ Casino Transport
Church Bus
Classic Cars
Courtesy Bus
Day Care
Drum & Bugle Corp and Amateur Sports Players
Other (describe):
Employee Transportation
Employment Service
Funeral Home
Hotel/Motel Courtesy Bus
Inter City Bus
Kiddie Cab (internal)
Limousine Service
Luxury Sedan/SUV Service
Medical Van
Prisoner Transport (internal)
School Bus
Scout Bus
Seasonal Recreation Transport
Sightseeing Bus
Ski Bus
Social Service
Taxicabs (internal)
Trams (internal)
Transportation of Elderly
Transportation of Railroad
Employees (internal)
Trolley Bus (internal)
Urban Bus (internal)
Van Pools (internal)
Public Autos - NOC
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
1 8
Identify Metropolitan Areas Traveled Through or Into
Cities other than above or regular routes:
Atlanta
Balt.-Washington
Boston
Buffalo
Charlotte
Chicago
Cincinnati
Cleveland
Dallas/Ft. Worth
Denver
Detroit
Hartford
Houston
Indianapolis
Jacksonville
Kansas City
Little Rock
Los Angeles
Louisville
Memphis
Miami
Milwaukee
Mpls./St. Paul
Nashville
New Orleans
New York City
Oklahoma City
Omaha
Orlando
Philadelphia
Phoenix
Pittsburgh
Portland
Richmond
St. Louis
Salt Lake City
San Diego
San Francisco
Seattle
Tampa
Tulsa
Percent of Trips:
0 - 75 Miles
76 - 100 Miles
301 Miles +
Longest Trip One Way:
Miles
101 - 300 Miles
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
$ $
Yes
No
1.
Are filings required? If yes, complete
Filing Information
form.
2.
A.
Do you hire or employ any owner operators?
B.
Are the owner operators and their vehicles scheduled on this application?
If no, explain:
C.
Do owner operators accept passengers from any other companies (including ridesharing and
transportation network companies)?
If yes, explain:
D.
Do you require owner operators to carry their own insurance?
If yes, minimum limit required:
E.
Do any other companies provide insurance coverage for owner operators?
If yes, explain:
F.
Percent of annual revenue from owner operators:
%
3.
Do you arrange for transportation of passengers for companies other than your own?
If yes, explain:
4.
A.
Percent of your annual income derived from transportation network companies, ridesharing or social
media apps:
%
Describe these operations:
B.
Percent of owner operator's income derived from transportation network companies, ridesharing or
social media apps:
%
Describe these operations:
5.
Do you transport passengers across states lines?
6.
Is all equipment operated under the applicant's authority scheduled on the application?
If no, attach explanation.
7.
Is all owned equipment scheduled on this application? If no, attach explanation.
8.
Do you lease your vehicles to others?
If yes, who must provide primary liability coverage?
You
Lessee
9.
Do you lease, rent, hire or borrow vehicles?
If yes, do you provide the driver?
If vehicles are leased, rented or hired, complete questions below and attach copy of lease agreement.
If no, skip to question #10.
A.
Describe type of vehicles rented, hired and leased:
B.
On what basis are they leased?
C.
Provide annual cost of hire or # of trips
D.
Are vehicles leased with driver?
E.
Are leased vehicles included in this application for insurance?
If no:
(1)
Is there a written lease agreement stating the lessor will
provide primary auto liability coverage while leased to you?
(2)
Limit of Liability required
(3)
Do you secure evidence the lessor has primary auto liability
coverage?
(4)
Does the lease state that the lessor agrees to provide you with
30 days advance notice if their insurance coverage is being
cancelled or reduced?
Permanent
Basis
Temporary/
Trip Basis
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
2 8
Yes
No
Location(s)
# Units
Address, City, State
10.
Any personal use of vehicles?
A.
If yes, provide % and details:
B.
Are there any household drivers under age 25? All drivers must be shown in Driver Information section.
11.
Is any portion of your operation seasonal? If yes, explain:
12. Do you do any package delivery?
13.
Do you own/operate any other transportation companies? If yes:
A.
Name(s):
B.
Describe operations:
14.
Do you operate more than one location? If yes, provide the following:
15.
Do any of your vehicles have special equipment for transporting physically impaired?
If yes, complete Physically Impaired and Senior Citizens section.
16. Are drivers allowed to take vehicles home when not in use? If yes, how often:
17.
Percent of your trips to and from the airport:
%
18.
Percent of your trips arranged 24 hours in advance:
%
19.
Indicate how vehicles are stored (open lot, fenced, lighted lot, in garage):
20.
Do you have a General Liability policy?
21.
Do you belong to any local, state or national associations? If yes, which ones:
22.
Do you use non-owned autos? If yes, describe:
A.
Frequency of use:
B.
Type of non-owned autos used:
C.
Do you require employees to have their own insurance?
LIMOUSINES AND SEDANS
Yes
No
1.
Are you registered or licensed as a:
Limousine
Yes
No
Taxi
Yes
No
2.
Do any vehicles have a fare box or meter?
3.
Do you charge by the:
Hour
Trip
Miles
4.
Are your vehicles dispatched or do you share dispatch services with another entity?
If yes, explain:
5.
Are vehicles ever leased to drivers?
If yes, explain:
6.
Do drivers wear formal chauffeur's attire?
7.
If you have corporate contracts to provide transportation, list clients:
8.
How do you solicit your business?
Advertising
Social Media/Rideshare
Curbside
Other (describe):
9.
Do any vehicles have specialized equipment (i.e. hot tubs)?
If yes, describe:
10.
Percent of your trips which are unscheduled:
%
FULL SIZE VANS (12 to 15 PASSENGER)
Yes
No
1.
Are licensed drivers required to have a CDL with a passenger endorsement or chauffeur license?
2.
Are driver assistants on board the vans?
3.
Do you have any cargo racks on your vehicles?
4.
Do you tow trailers with your van?
5.
Is seat belt usage mandatory for all drivers and passengers?
6.
If the van is 15 passenger configuration, is the rear-most seat removed?
7.
Have you trained your drivers specifically on how to safely operate the full size van?
If yes, describe:
SCHOOL BUS
Yes
No
1.
Are all buses school bus yellow?
2.
Are all buses equipped with stop arms, flashers, and area mirrors?
3.
Are any vehicles other than school buses utilized to transport students?
If yes, describe:
4.
Do you provide transportation services in addition to school transportation?
If yes, describe:
5.
Do you have handicap accessible vehicles?
If yes, complete Physically Impaired and Senior Citizens section.
6.
Are driver assistants on board the buses?
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
3 8
PHYSICALLY IMPAIRED AND SENIOR CITIZENS
Yes
No
With
Loading Ramps
Wheelchair Lifts
No Special Equipment
2.
Indicate number of vehicles equipped with the following wheelchair tie-down mechanisms:
3 point tie down 4 point tie down
Other (describe):
3.
Are any vehicles not equipped with both lap and shoulder harnesses for the passengers?
If yes, describe:
4.
Describe management's experience operating this class of business:
5.
Do all drivers have a minimum of one year experience transporting elderly or those with physical
disabilities?
If no, explain:
6.
Do you load passengers with walkers on the wheelchair lift?
If yes, describe the process:
7.
Do you transport patients needing emergency medical attention?
8.
Do you ever assist passengers from inside their homes, e.g. from their beds to their wheelchairs?
9.
Have all drivers completed formal passenger assistance training?
1.
Number of vehicles owned by you:
Vans
Buses
Explain:
Other
DRIVER INFORMATION
(Last, First, Middle)
Date of Birth
License Number
State
Must be Completed for All Drivers
Date of Hire
Driver Name
# Yrs. Driving
Similar Equip.
Use N-3077 if additional space is needed for Driver Information, Insurance History, Schedule of Autos or Additional Interests.
DRIVER VIOLATION HISTORY - Past 3 Years
(Last, First, Middle)
Violations/Convictions
#
Driver Name
Accidents
Speeds
Other Than Speeds
# Minor
# Majors
Date of Most Recent
Moving Violation/Conviction
# Minor
DRIVER EMPLOYMENT HISTORY
Prior Employment and Full Address
Employment
of Unit
Driver Name
(Last, First, Middle)
Dates of
Type
Provide three years employment history for each driver if you have not had commercial insurance for past two years or for
drivers employed less than two years operating vehicles with seating capacity in excess of 15 passengers. Do not indicate
"self-employed" unless you have insurance in your name. Use form TF-079 for additional drivers.
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
4 8
DRIVER HIRING, TRAINING AND SAFETY
Yes
No
1.
Which of the following is part of your driver screening/hiring process:
Employment background check
Pre-employment drug test
Criminal background check
Road test
Motor vehicle record (MVR) review
Other (describe):
2.
Which of the following is part of your driver performance management process:
Annual review of driver's driving record (MVR)
Incentives for violation-free and accident-free driving
Periodic review of accidents/incidents
Formal corrective action procedures
Review of electronic engine data/video event recorders
Driver safety training
3.
Do you adhere to a written vehicle inspection and maintenance program?
If yes, describe or attach program:
MILEAGE
Past 12 Months
Units
Next 12 Months
Mileage Per Unit
Total Mileage
INSURANCE HISTORY AND LOSS EXPERIENCE
Yes
No
Prior Carrier Name
Policy Number
# Units
Insured
#
Losses
Prior Carrier Effective Dates
Coverage
Type*
1.
Has an insurance company cancelled or non renewed your policy in the last 3 years?
(Missouri Applicants - Do not answer this question.)
If yes, explain:
2.
Prior years insurance under business name with:
Primary Auto Liability:
Physical Damage:
Cargo:
3.
Indicate other company name(s) you have operated under in the last 3 years:
Company Names:
Insurance Provider(s):
4.
Provide 3 years Prior Carrier Information. Hard copy loss runs must be provided for last 4 years for risks with more than
10 units.
*Type: L=Prim. Liab. P=Phy. Dmg. C=Cargo GL=Genl Liab. IM=Inland Marine
to
to
to
Accident
Amount of Accident
Description
Date of
LOSS HISTORY - Past 3 Years (including Drivers no longer employed)
Driver Name
(Last, First, Middle)
SCHEDULE OF AUTOS / VEHICLE COVERAGE OPTIONS
All units you own or are leased to you must be scheduled and insured if filings are to be made.
To ensure Electronics (as defined by the policy), along with tarps, chains or binders are covered, include the value in each
auto's stated value.
Finance Value Coverage
- If selected, the Stated Limit of each auto must be equal to or greater than the outstanding
financial obligation for that auto in order for the Finance Value Coverage to apply.
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Ownership:
Make
Radius
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVC/CMC
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Owned
Employee Owned
Leased Without Driver
Leased With Driver
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
5 8
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Ownership:
Make
Radius
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVC/CMC
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Owned
Employee Owned
Leased Without Driver
Leased With Driver
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Ownership:
Make
Radius
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVC/CMC
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Owned
Employee Owned
Leased Without Driver
Leased With Driver
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Ownership:
Make
Radius
Seating Capacity
Length of Stretch
Name of Coach Builder/Modifier
QVC/CMC
Finance Value
Lease - Loan
Towing & Labor
Additional Coverages:
Owned
Employee Owned
Leased Without Driver
Leased With Driver
Alternative Fuel Vehicle
Hybrid Electric
All Electric
Fuel Cell
Natural Gas
Propane
Other, Specify:
*Vehicle Type Legend
AMB - Ambulance
BUS - Bus
LIB - Limousine Bus
LIM - Limousine
LUX - Luxury Sedan
MEP - Mobile Equip-Power
MEN - Mobile Equip-NonPower
MTR - Motor Home
NLX - Non Luxury Sedan
PU - Pickup
SUV - Sport Utility Vehicle
TRC - Tractors
TRL - Trailers
TRK - Trucks
VAN - Van (Full Size)
VNS - Van (Small)
ADDITIONAL INTERESTS
Unit #
Address
State
Name
City
ZIP Code
Type*
Type*:
AI - Additional Insured AL - Lessor; Additional Insured and Loss Payee LP - Loss Payee
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
6 8
COVERAGES
AUTO LIABILITY
EMPLOYERS NONOWNERSHIP LIABILITY
Number of Employees
HIRED AUTO LIABILITY
Limits:
PHYSICAL DAMAGE DEDUCTIBLES
Comprehensive
Collision
Specified Causes of Loss
Limit
CARGO
Deductible
COMBINED DEDUCTIBLE
Coverage included unless declined.
Decline Combined Deductible
RENTAL REIMBURSEMENT
Selected Units OR All Units
Days of Coverage:
30
120
OR
MEDICAL PAYMENTS
Cost of Hire
CSL
Limits
HIRED AUTO PHYSICAL DAMAGE
Complete and Attach Supplement
OPTIONAL CARGO COVERAGES: (Check all that apply)
Aluminum, Copper
Additional Earned Freight Increase Limit to $5,000
Electronics
Hard Liquor
Pharmaceuticals
Amount Per Day:
Diminishing Deductible
Temperature Control
Aggregate Deductible
Basket Deductible
Personal Effects Coverage
Note: If you transport passengers for-hire interstate, an FMCSA filing is required and you must carry the following minimum
limits: Seating capacity of 15 or less: $1,500,000 OR Seating capacity of 16 or more: $5,000,000.
UNINSURED / UNDERINSURED MOTORISTS AND NO-FAULT OPTIONS
UNINSURED MOTORIST
UNDERINSURED MOTORIST
PERSONAL INJURY PROTECTION
Coverage and limit choices in this section are for quoting purposes only. A separate Northland Insurance Company
Supplemental Uninsured Motorists/Underinsured Motorists and Personal Injury Protection Application(s) must be
completed and signed by the applicant when binding coverage.
For information about how Northland compensates its agents, brokers and program managers, please visit this website:
http://www.northlandins.com/Producer_Compensation_Disclosure.asp
If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance
Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102.
This application, including any material submitted in conjunction with the application or any renewal, does not amend the
provisions or coverages of any insurance policy or bond issued by Northland. It is not a representation that coverage does
or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and
circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of
coverage referenced in this document can depend on underwriting qualifications and state regulations.
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
7 8
FRAUD STATEMENTS
ARKANSAS, MARYLAND, AND NEW MEXICO:
Any person who knowingly (or willfully in MD) presents a false or fraudulent
claim for payment of a loss or benefit or knowingly (or willfully in MD) presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW JERSEY:
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.
MAINE, TENNESSEE, 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. Penalties may include imprisonment, fines, and denial
of insurance benefits.
OKLAHOMA:
WARNING: 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 information is guilty of a felony.
OREGON:
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 may be guilty of a crime and may be subject to fines and
confinement in prison.
UTAH:
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or
fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health
care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.
ALL OTHER STATES:
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties.
SIGNATURES
I authorize Northland Insurance Companies to obtain a copy of any Motor Vehicle Report for rating/underwriting the
insurance for which I have applied. I also understand that a routine inquiry may be made providing information concerning
my character, general reputation, personal characteristics and mode of living. Upon written request, information as to the
nature and scope of the report will be provided to me.
Disclosure:
In connection with this application for commercial automobile insurance, we may review a credit report or
obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third
party in connection with the development of the insurance score. The credit report/credit-based insurance score will not be
used for any purpose other than the underwriting of the commercial automobile insurance policy for which you have applied.
I authorize Northland Insurance Companies to obtain a credit report, including but not limited to a credit-based insurance
score based on personal information provided. This authorization is valid for future reports obtained for renewal policies
with Northland Insurance Companies.
I hereby certify that the foregoing statements and answers are a just, full and true exposition of all the facts and
circumstances with regard to the risk to be insured, insofar as same are known to me, and the same are hereby made as the
basis and condition of the insurance. By signing below, I affirm full knowledge of and adherence to current D.O.T. Safety
Regulations, and hereby apply for insurance with respect to the coverages stated herein.
State Notices:
Montana:
A single loss is among the insurance company's criteria for nonrenewal.
South Carolina:
The insurer can cancel this policy for which you are applying without cause during the first 90 days. That is
the insurer's choice. After the first 90 days, the insurer can only cancel this policy for reasons stated in the policy.
APPLICANT'S SIGNATURE
DATE
APPLICANT'S PRINTED NAME
APPLICANT'S TITLE
PRODUCER'S SIGNATURE
PHONE #
FAX #
TL-261 (4/15)
Page
of
© 2015 The Travelers Indemnity Company. All rights reserved.
8 8
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PUBLIC AUTO APPLICATION (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document