Fillable Pilot Car Insurance Program Application General'Information' Application must

Fill Online, Printable, Fillable, Blank Pilot Car Insurance Program Application General'Information' Application must Form

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

Pilot Car Insurance Program Application General'Information' Application must

On average this form takes 91 minutes to complete

The Pilot Car Insurance Program Application General'Information' Application must form is 7 pages long and contains:

  • 1 signature
  • 13 check-boxes
  • 352 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
Pilot Car Insurance
Program Application
6/9/2019 1 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
Application must be completed accurately and completely. Incomplete applications will be returned to the
applicant. The Pilot Car Program is available in most states.
General'Information'
Today's Date: ______________________________ Requested Effective Date: ________________________
Company Name: ___________________________________ FEIN and SSN: ___________________________
Physical Address: _________________________________________________________________________
City: ________________________________ State: ________ Zip: ___________ County: _________________
Mailing Address: __________________________________________________________________________
City: ________________________________ State: ________ Zip: ___________ County: _________________
Contact: __________________________________________ Title: __________________________________
Telephone: _____________________ Fax: _____________________ Email: __________________________
Type of Business: mSole Proprietor m Partnership m Corporation m Other __________________
Business Start Date: _______________ Total Piloting Experience:: ________ New Venture: m Yes m No
Coverage Requested:
q Commercial Auto q General Liability q Professional Liability* q Equipment Coverage
Limits of Liability:
Auto Liability Limit
1, 2
m $1,000,000 m $500,000
Uninsured/Underinsured Motorist B.I./P.D.
1
m $1,000,000 m $500,000
Medical Payments
3
m $5,000
General Liability
4
m $1,000,000/$2,000,000
Professional Liability m $1,000,000 m $500,000 m $250,000
Bodily Injury/Property Damage Sublimit m $100,000 (included) m $250,000
6
m $500,000
6
Excess Liability (Commercial Umbrella) m $1,000,000
Equipment Coverage m $5,000 m Other
1
Auto Liability and Uninsured/Underinsured Motorists limits must be equal.
2
Higher limits may be available by excess liability.
3
PIP (Personal Injury Protection) will be included where required at state minimum. Higher limits if requested.
4
Professional Liability is on a Claims Made form
5
Higher BI/PD sublimits subject to underwriting approval
Current Insurance: _________________________________ Expiration Date: _________________________
Current Limit: _____________________________________ Current Premium: ________________________
Number of Consecutive Years of Insurance Coverage __________
List years of total Gross Annual Revenue:
Last 12 Months Next 12 Months (Estimate)
$ ____________________________ $ __________________________
Do you have a personal automobile policy? m Yes m No
Do you have a contract for your services? m Yes m No *Please attach a copy
Clear Form
Pilot Car Insurance
Program Application
6/9/2019 2 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Vehicle'Schedule'
1. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
2. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
3. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
Office use only: Symbol 7 applies to Liability, Medical Payments, Uninsured/Underinsured Motorist, Comprehensive, Collision, Symbol 8 for Liability.
Include BAP Plus on all autos with physical damage coverage
There are no radius or mileage restrictions with this program.
Pilot Car Insurance
Program Application
6/9/2019 3 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Drivers'
1. Name: ________________________________________ DOB: ___________________ Gender: ________
Marital Status: _________________________________ DL Number: _____________ State: __________
CDL: m Yes m No Year Obtained _______________
m Yes m No Front Pilot Car m Yes m No Rear Steering/Tillering
m Yes m No Rear Pilot Car m Yes m No Rigging
m Yes m No Flagging/Traffic Control m Yes m No Brokering/Subcontractors
m Yes m No Height Pole m Yes m No Hot Shot
m Yes m No Route Surveys
Length of experience for each service above: ________________________________________________
____________________________________________________________________________________
Violations, Accidents or Claims Last 7 Years
q
Check Here if None
Date
Description of Occurrence/Claim
Amount Paid
Claim Status
1
m Open m Closed
2
m Open m Closed
3
m Open m Closed
4
m Open m Closed
*Loss runs MUST be provided for the last 3 years before any processing of the application can occur.
*Include details on any auto, general liability, or professional liability claims in last 7 years.
2. Name: ________________________________________ DOB: ___________________ Gender: ________
Marital Status: _________________________________ DL Number: _____________ State: __________
CDL: m Yes m No Year Obtained _______________
m Yes m No Front Pilot Car m Yes m No Rear Steering/Tillering
m Yes m No Rear Pilot Car m Yes m No Rigging
m Yes m No Flagging/Traffic Control m Yes m No Brokering/Subcontractors
m Yes m No Height Pole m Yes m No Hot Shot
m Yes m No Route Surveys
Length of experience for each service above: ________________________________________________
____________________________________________________________________________________
Violations, Accidents or Claims Last 7 Years
q
Check Here if None
Date
Description of Occurrence/Claim
Amount Paid
Claim Status
1
m Open m Closed
2
m Open m Closed
3
m Open m Closed
4
m Open m Closed
*Loss runs MUST be provided for the last 3 years before any processing of the application can occur.
*Include details on any auto, general liability, or professional liability claims in last 7 years.
Pilot Car Insurance
Program Application
6/9/2019 4 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
3. Name: ________________________________________ DOB: ___________________ Gender: ________
Marital Status: _________________________________ DL Number: _____________ State: __________
CDL: m Yes m No Year Obtained _______________
m Yes m No Front Pilot Car m Yes m No Rear Steering/Tillering
m Yes m No Rear Pilot Car m Yes m No Rigging
m Yes m No Flagging/Traffic Control m Yes m No Brokering/Subcontractors
m Yes m No Height Pole m Yes m No Hot Shot
m Yes m No Route Surveys
Length of experience for each service above: ________________________________________________
____________________________________________________________________________________
Violations, Accidents or Claims Last 7 Years
q
Check Here if None
Date
Description of Occurrence/Claim
Amount Paid
Claim Status
1
m Open m Closed
2
m Open m Closed
3
m Open m Closed
4
m Open m Closed
*Loss runs MUST be provided for the last 3 years before any processing of the application can occur.
*Include details on any auto, general liability, or professional liability claims in last 7 years.
Additional'Information'
m Yes m No Any vehicles not solely owned and registered to applicant?
If yes, please explain ______________________________________________________
m Yes m No Are you requesting coverage for an employee using their own vehicle?
m Yes m No Any vehicles leased or rented to others?
If yes, provide copy of lease.
m Yes m No Do you escort only loads transporting hazardous materials?
m Yes m No Are any vehicles to be covered used only by family members?
If yes, include driver information for each.
m Yes m No Are any drivers covered by workers’ compensation?
m Yes m No Do you permit non-employee passengers during trips?
m Yes m No Do you participate in any ride-sharing services such as Uber or Lyft? (Note: Policy
excludes coverage for these services.)
List primary operating states: ________________________________________________________________
________________________________________________________________________________________
List all certifications: _______________________________________________________________________
________________________________________________________________________________________
List any added safety devices (voice recorders, camera, GPS): ______________________________________
________________________________________________________________________________________
Pilot Car Insurance
Program Application
6/9/2019 5 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Basic'Operations'
Services Provided Length of Experience % of Total Operations
m Yes m No Front Pilot Car ________________________ _______________________
m Yes m No Rear Pilot Car ________________________ _______________________
m Yes m No Flagging/Traffic Control ________________________ _______________________
m Yes m No Height Pole ________________________ _______________________
m Yes m No Route Surveys ________________________ _______________________
Height'Pole'
q
'N/A'
m Yes m No Do you perform height pole work?
If yes, please explain ______________________________________________________
Is height pole/fastening equipment homemade or manufactured? _________________
Height Pole Guidelines: Pole must be non-conductive, flexible, non-destructive, and must have secure
fastening device in place to prevent slipping.
m Yes m No Does your height pole use any compression fittings?
Please describe all training, experience, and safeguards used to prevent claims resulting from height pole
work: ___________________________________________________________________________________
________________________________________________________________________________________
* PROVIDE PHOTO OF ALL HEIGHT POLE EQUIPMENT FOR EACH VEHICLE. (REQUIRED)
Route'Surveys'
q
'N/A'
m Yes m No Are you contracted to perform route surveys?
m Yes m No Do you physically drive the route before producing a survey?
m Yes m No Do you charge a fee to perform route surveys?
m Yes m No Have you received any route survey education/training?
If yes, please explain ______________________________________________________
m Yes m No Do you maintain files on how a survey was completed?
If yes, how long do you maintain the route survey files? __________________________
m Yes m No Do you provide a written guarantee for completed surveys?
If yes, please explain ______________________________________________________
m Yes m No Does anyone else in your company perform route surveys?
If yes, please explain ______________________________________________________
How many years route survey experience? ____________________________________
m Yes m No Is there a pre-trip coordination and planning meeting?
m Yes m No Are permit/routing documents provided at these meetings?
Pilot Car Insurance
Program Application
6/9/2019 6 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Additional'Operations'!"#$%&'()(*)+,-./-$./.(01)
Services Provided Length of Experience Classes/Training % of Total Operations
m Yes m No Rear Steering/Tillering _______________ _______________ _______________
m Yes m No Rigging/Secure Cargo _______________ _______________ _______________
m Yes m No Brokering/Subcontractors _______________ _______________ _______________
m Yes m No Hot Shot _______________ _______________ _______________
Brokering/Subcontractors'
q
'N/A'
m Yes m No Do you subcontract work with other drivers/companies?
m Yes m No Do they provide you with a copy of their current policy showing matching limits of
Auto Liability, General Liability, and Professional Liability?
m Yes m No Are you a certificate holder or additional insured on the subcontractor's insurance?
$ _______________ Annual revenue for subcontract or brokered work.
m Yes m No Are you paid a percentage of each brokered load?
If yes, what percentage? ___________________________________________________
'
Pilot Car Insurance
Program Application
6/9/2019 7 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Applicant'Signature'and'Fraud'Statement'
Notice to Applicants of All States Except Colorado and Pennsylvania
Any person who knowingly, with the intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any material false information or conceals for the
purposes 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 and denial of insurance benefits.
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 policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to Colorado division of insurance within
the department of regulatory agencies.
Notice to Pennsylvania Applicants
Any person who knowingly, and with the intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any material false information or conceals for the
purposes 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.
Important Notice
Failure to report claim(s) made against you during the current term of your policy or failure to report any facts,
circumstances or events that could give rise to a claim against you to your current insurance company PRIOR TO
expiration of your current policy term may result in a lack of coverage. An authorized representative who is an
active owner, officer, or partner of your firm must sign this application within thirty (30) days prior to the policy
inception date.
By my signature below, I authorize V. R. Williams & Company and/or Central Mutual Insurance Company to
obtain my motor vehicle report and other consumer reports necessary to evaluate my insurability.
Applicant's Signature: _______________________________________________ Date: _____________________
Name and Title (please print): ___________________________________________________________________
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

Pilot Car Insurance Program Application General'Information' Application must

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 15 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document