Fillable Public Application Individual/Proprietorship Partnership Corporation Other Business Phone (RT Specialty)

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Public Application Individual/Proprietorship Partnership Corporation Other Business Phone (RT Specialty)

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Public Application
Policy Term From:
To
1. Name (and "dba")
Individual/Proprietorship Partnership Corporation Other Business Phone Number
2. Mailing Address
City State Zip
3. Premises Address
City State Zip
4. Person to contact for inspection (name and phone number)
5. Have you ever had insurance with one of the companies listed at the top of this page?
Yes No
If yes, Policy Number(s)
Effective Date(s)
DESCRIPTION OF OPERATIONS
6. Describe business
Years experience
New Venture? Yes No
7. Is this your primary business?
Yes No If no, explain
Is your business seasonal?
Yes No Is your business for hire/for profit? Yes No
8. Have you ever filed for Bankruptcy?
Yes No If yes, when Explain
9. Gross receipts last year
Estimate for coming year Business for sale? Yes No
10. Do you operate in more than one state?
Yes No If yes, list states
11. What is the largest city entered within your radius of operation?
LIABILITY COVERAGE C Complete for desired coverages by indicating limits of insurance.
LIABILITY
Split Limits
Bodily Injury
Property Damage
Combined Single
Limit BI & PD
Each Person
Each Accident
Each Accident
Medical
Payments
Personal Injury
Protection
(where
applicable)
IF PHYSICAL DAMAGE COVERAGE
DESIRED B REFER TO FOLLOWING
PAGE.
COMPLETE HIRED AND NON-OWNED
SUPPLEMENT IF COVERAGE DESIRED.
APPLICABLE PERSONAL INJURY PROTECTION, UNINSURED AND/OR UNDERINSURED
MOTORISTS INSURANCE SELECTION/REJECTION PAGE IS REQUIRED TO BE COMPLETED AND
SIGNED BY THE NAMED INSURED WITH THE SUBMISSION OF THIS APPLICATION.
DRIVER INFORMATION C If additional space is needed, attach separate listing.
Driver's Licenses
Experience
Driver's Name
Date of Birth
State
Number
Class/Type
(i.e. CDL)
Years
Licensed (in
Class/Type)
Type of Unit
(Bus, Van,
etc.)
No. of
Years
1.
2.
3.
4.
5.
Accidents and Minor Moving Traffic
Violations in Past 5 Years
Major Convictions
(DWI/DUI, Hit & Run, Manslaughter, Reckless,
Driving While Suspended/ Revoked, Speed
Contest, other felony)
No. Years
Previous
Commercial
Driving
Experience
Date of Hire
No. of
Accidents
Date(s)
No. of
Violations
Date(s)
Describe Conviction
Date(s)
Employee (E)
Ind. Cont. (IC)
Owner/Op. (O/O)
Franchisee (F)
PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.
M-4443e VA (12/2007) Public Application Page 1 of 5
Submit Application
Atlantic Specialty Lines, Inc.
9020 Stony Point Parkway
Suite 450
Richmond, VA 23235
(800)368-2095 FAX: (804)320-7280
12. What is the basis for driver(s) pay? Hourly Trip Mileage Other, explain
13. Are drivers covered by Workers Compensation?
Yes No Minimum years driving experience required
14. Are vehicles owner-driven only?
Yes No Do you agree to report all newly hired operators? Yes No
15. Are drivers ever allowed to take vehicles home at night?
Yes No If yes, will family members drive? Yes No
16. Do you order MVR's on all drivers prior to hiring?
Yes No Driver's maximum driving hours daily, weekly
SCHEDULE OF AUTOS/VEHICLES C Describe all vehicles for which application is made for insurance.
Veh.
No.
Model
Year
Vehicle Make
Body
Type/Model
Full Vehicle Identification
Number
Orig.
Mfg.
Seating
Cap.
Principal Garaging
Location
(City & State)
Radius
of
Opera-
tion
Annual
Mileage
Per
Vehicle
(A) Anti-Lock
Brakes,
(B) Air Bags
or (C)
Wheelchair
Lift
1
2
3
4
5
6
7
8
9
10
PURPOSE OF USE ABBREVIATION MUST BE SELECTED FOR EACH VEHICLE
Veh.
No.
Purpose
of Use
Length of
Limo Stretch
1
2
3
4
5
6
7
8
9
10
AB Airport Bus or Van
APS Airport Parking/Rental Car Shuttle
AT Athlete Bus (a) Professional Athlete
(b) Non-Professional Athlete
BB Bingo/Casino Bus
SBG Boy/Girl Scout Bus
CB Charter Bus (a) Interstate (b) Intrastate
CHB Church Bus
CTB City Transit Bus (Urban Bus)
CRB Courtesy Bus (a) Hotel (b) Medical (c) Other
DC Day Care/Day Nursery
ET Employee Transportation
Railroad Employees (a) For Profit (b) Not For Profit
Farm Labor Bus (c) For Profit (d) Not For Profit
Other (e) For Profit (f) Not For Profit
ICB Inter-City Bus (attach route scheduled)
L Limousine (a) Transportation to Airport >_ 50%
(b) Super-Stretch (> 120") (c) Regular
ME Musician & Entertainer Bus
(a) Professional Entertainer
(b) Non-Professional Entertainer
MV Medivan/Medical Transport/Non-Emergency
Ambulance
(a) For Profit ( b) Not For Profit
PT Prisoner Transfer
SB School Bus (a) Public Owned (b) Other
(c) Private or Parochial Owned
SC Senior Citizens Center Auto
SH Shuttle (a) Tourist (b) Wilderness
(c) All Other
SSB Sightseeing Bus
SKB Ski Bus
SSA Social Service Agency (a) Group Home (b) Other
TX Taxicab
TM Tram
T Trolley
PHYSICAL DAMAGE COVERAGE C Complete spaces below in detail for each respective auto/vehicle described above.
Physical Damage Deductible
Veh.
No.
Date
Purchased
Cost When
Purchased
Current Stated Value
(excluding permanently
attached equipment)
Value of Permanently
Attached Equipment
Total Stated Amount
to be Insured
Comprehensive
Spec. C of Loss
Collision
1
2
3
4
5
6
7
8
9
10
17. Any loss payees?
Yes No If yes, give name and address of mortgagee/loss payee for each vehicle
Public Application Page 2 of 5
LOSS EXPERIENCE C Provide prior insurance carriers information for past full three years.
Policy Term
Premium
Total Amount Claims Paid & Reserves
From
To
Insurance Company Name
No. of Motor
Powered
Vehicles
No. of
Accidents
Liab
Phys Dam
BI
PD
Comp/Coll
Other
/ /
/ /
/ /
/ /
/ /
/ /
18. Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage
sought in this application?
Yes No If yes, provide complete details
19. Have you ever been declined, cancelled or non-renewed for this kind of insurance?
Yes No
If yes, explain
20. Is the transportation of people your primary business?
Yes No Are vehicles leased to drivers? Yes No
21. Do you transport physically disabled individuals?
Yes No If yes, what percentage of the time?
22. Are vehicles equipped with fare box or meter?
Yes No Do you have a scheduled route? Yes No
23. Do you ever transport unscheduled passengers?
Yes No Minimum number of hours rented Minimum charge
24. Number of vehicles owned Limos
Vans Buses Other
25. Number of vehicles leased Limos
Vans Buses Other
FILING INFORMATION
26. Is an FHWA filing required?
Yes No If yes, MC number
What authority do you have?
Broker Common Contract
27. If you hold a Brokers license, identify name filed with FHWA, FHWA docket no. and receipts from brokerage operations
28. If you are an interstate regulated carrier, identify your registration or base state
29. Is an intrastate
filing needed? Yes No If yes, show state and permit number
30. Show exact name and address in which permits are issued
31. Is MCS 90 endorsement needed?
Yes No
32. Is our policy to cover all vehicles owned, operated or under lease to applicant?
Yes No If no, explain
33. Do you enter Canada?
Yes No Do you enter Mexico? Yes No If yes, where
34. Have you ever changed your operating name?
Yes No Do you operate under any other name? Yes No
35. Do you operate as a subsidiary of another company?
Yes No
36. Do you own or manage any other transportation operations that are not covered?
Yes No
37. Do you lease your authority?
Yes No Do you appoint agents or hire independent contractors to operate on your behalf? Yes No
38. Have you purchased, sold or applied for authority over the past 3 years?
Yes No
39 Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.)?
Yes No
40. Is evidence/certificate(s) of coverage required?
Yes No
41. Please explain any "yes" answer to questions 34 through 40
42. Do you have agreements with other carriers for the interchange of vehicles or transportation of passengers?
Yes No
If yes, attach a copy of current agreements and complete the following:
(a) With whom has such agreement(s) been made?
(b) Do the parties named in (a) carry automobile liability insurance?
Yes No
If yes, name of insurance company and limits of liability (Bodily Injury & Property Damage)
(c) Under whose permit does each of the parties to the agreement(s) operate?
(d) Is there a hold harmless in the agreement(s)?
Yes No
43. Do you barter, hire or lease any vehicles?
Yes No If yes, explain
44. Additional comments:
Public Application Page 3 of 5
SELECTION OF LIMITS FOR UNINSURED/UNDERINSURED MOTORISTS COVERAGE
(Virginia)
Virginia Insurance Code Section 38.2-2206 provides that policies of insurance which provide bodily injury or property damage liability
insurance relating to the ownership, maintenance or use of a motor vehicle issued or delivered in the Commonwealth of Virginia must
provide Uninsured motor vehicle coverage in limits not less than $25,000 because of bodily injury to or death of one person in any
one accident and $50,000 because of bodily injury to or death of two or more persons in any one accident, and $20,000 because of
injury to or destruction of property of others in any one accident. Such policies must also provide coverage for bodily injury or
property damage caused by the operation or use of an Underinsured motor vehicle.
Under Virginia law, the limits of Uninsured/Underinsured motorist coverage must equal the limits of the liability insurance provided by
your policy unless additional coverage is rejected by any one named insured. Therefore, if you purchase liability insurance in
amounts greater than the state mandated minimum limits of $25,000/50,000/20,000, your Uninsured/Underinsured motorist coverage
limits will equal these greater limits.
If you purchase liability insurance limits in excess of $25,000/50,000/20,000 you may reject the increased limits of
Uninsured/Underinsured motorist coverage. If you reject the increased limits of Uninsured/Underinsured motorist coverage you must
at a minimum purchase the state-mandated limits of $25,000/50,000/20,000. You may also choose to purchase
Uninsured/Underinsured motorist coverage limits in excess of the state-mandated minimum amount yet less than your liability
insurance limits. Ask your producer for coverage limits offered.
The rejection of the additional limits of Uninsured/Underinsured motorist insurance by any one named insured is binding on all
insureds under such policy.
In accordance with the Virginia law, the undersigned insured (and each of them):
(Applicable item marked 7)
Selects Uninsured/Underinsured motor vehicle coverage limits in the amount of $25,000/50,000/20,000. These are the lowest
coverage limits which may be purchased by law.
Selects Uninsured/Underinsured motor vehicle coverage limits which are lower than the liability limits under the policy but
higher than the state-mandated minimum limits. Selected limits for Uninsured/Underinsured motorist coverage are:
(Enter limits if a separate limit of liability applies)
$
Bodily Injury each person
$
Bodily Injury each accident
$
Property Damage each accident
(Enter limit if a single limit of liability applies)
$
Each accident
MEDICAL EXPENSE AND INCOME LOSS BENEFITS SELECTION
Medical Expense Benefits
- Choose one:
G Reject
G Accept If accepting, choose one: G $500 G $1000 G $2000 G $5000
Income Loss Benefits
- Choose one:
G Reject
G Accept
I have indicated my choice above ("X" indicates my choice):
Signature of Insured Signature of Insured
Date Policy Number
(Until you advise us otherwise in writing, your choices, as indicated above, will continue regardless of any addition or change in Auto
coverage on your current policy or addition of any Scheduled Autos.)
SIGNATURE IS ALSO REQUIRED ON LAST PAGE OF APPLICATION
Public Application Page 4 of 5
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MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the policy
effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is acting as
Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may not accept any
funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false, the
Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Interstate Commerce Commission requires a special endorsement to be
attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that
endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or
any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business
background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional
information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
Will premium be financed? Yes No If yes, with whom
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.
Witness Applicant's Signature Date
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE
Is this direct business to your office? If not, explain
Is this new business to your office?
If not, how long have you had the account?
How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Please quote Please bind at earliest possible date and issue policy
Please issue policy effective Coverage was bound by
(Time and Date Bound by General Agent) (Name of Person in Company General Agency's Office Binding Coverage)
Applicant's Representative's Name and Address Phone No.
Public Application Page 5 of 5
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Public Application IndividualProprietorship Partnership Corporation Other Business Phone (RT Specialty)

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Completed 13 December 2020

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