Fillable SUPPLEMENTAL QUESTIONNAIRE Hired Auto Coverage (RT Specialty)

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SUPPLEMENTAL QUESTIONNAIRE Hired Auto Coverage (RT Specialty)

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The SUPPLEMENTAL QUESTIONNAIRE Hired Auto Coverage (RT Specialty) form is 2 pages long and contains:

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  • 5 check-boxes
  • 102 other fields

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File type: PDF

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8877 North Gainey Center Drive • Scottsdale, Arizona 85258
www. scottsdaleins.com
SUPPLEMENTAL QUESTIONNAIRE
Hired Auto Coverage
Complete if hired auto coverage is desired.
1. Does applicant own any commercial vehicles? ........................................................................................... Yes No
Number of employees: Web site address:
2. Why is hired auto coverage being requested?
3. Number of hired autos:
4. Types of autos hired:
How are they used?
What is gross vehicle weight of commercial autos?
What is passenger capability of public autos?
5. What is the average term of lease?
6. What is the maximum distance in which a hired auto may be driven from the premises?
7. Does the applicant lease, hire, rent or borrow any auto, other than a private passenger type auto,
owned or leased by the applicant’s employees, partners or members of their household? ........................
Yes No
If yes, give details and how many:
8. Does any agent, independent contractor, or employee lease autos in the applicant’s name? .................... Yes No
If yes, explain:
9. At any time will you subcontract out work? .................................................................................................. Yes No
If yes, what work is subcontracted?
Cost to subcontract:
10. Estimated cost of hired autos:
This year: $ Last Year: $
Is the applicant involved in any arrangements for the borrowing or bartering for the use of autos? ........... Yes No
If yes, explain:
11. What percentage of the hired autos’ revenue is paid to owners of the autos? ............................................ %
12. Are drivers to be provided by the applicant to operate hired autos? ............................................................ Yes No
If no, will the drivers be required to provide Certificates of Insurance? ....................................................... Yes No
What are the minimum liability limits required by the lessee (applicant)?
13. Will the applicant be named as an additional insured on the lessor’s policy? ............................................. Yes No
14. Does the applicant own or control any subsidiary or is it affiliated with any other corporation? .................. Yes No
If yes, are vehicles leased from the subsidiary or affiliate?
CAS-STMT-5 (6-04) Page 1 of 2
Submit Application
15. What is the business of the subsidiary or affiliate?
16. Does the applicant have an ICC broker’s authority or provide a brokerage service? .................................. Yes No
17. Has applicant had any hired auto losses in the past? .................................................................................. Yes No
Applicant’s Signature: Date:
SUPPLEMENTAL QUESTIONNAIRE
Non-Owned Auto Coverage
1. Does applicant own any commercial vehicles? ........................................................................................... Yes No
Web site address:
2. Why is non-ownership liability coverage being requested?
3. What types of non-owned autos will be used in the applicant’s business?
How will they be used?
4. How often are non-owned autos used in the applicant’s business? Daily Weekly Monthly
Estimated number of hours per month:
5. What is the estimated annual mileage for use of all non-owned autos? ...................................................... miles
6. What is the maximum distance which a non-owned auto may be driven from the applicant’s premises? ... miles
7. Total number of non-owned autos used in the applicant’s business:
8. Total number of employees:
9. Total number of officers and partners:
10. If a social service operation, indicate total number of volunteers furnishing autos in the applicant’s operation:
Maximum number of volunteers at any one time:
11. Do employees lease autos on the applicant’s behalf? ................................................................................. Yes No
If yes, under whose name are autos leased? ........................................................................ Employees Applicant
12. Does the applicant require employees and volunteers to have their own insurance? ................................. Yes No
If yes, what are the minimum limits required?
Does the applicant require evidence of insurance? ..................................................................................... Yes No
13. Will the applicant use non-owned autos other than those owned by employees? ...................................... Yes No
If yes, describe relationship:
14. Does the applicant obtain motor vehicle records for all drivers? ................................................................. Yes No
15. Has applicant had any non-owned auto losses in the past? ........................................................................ Yes No
Applicant’s Signature: Date:
CAS-STMT-5 (6-04) Page 2 of 2
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SUPPLEMENTAL QUESTIONNAIRE Hired Auto Coverage (RT Specialty)

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Completed 13 December 2020

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