Fillable Special-Types-Application - M5550-PA_1210

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Special-Types-Application - M5550-PA_1210

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Special Types Application
COLUMBIA INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY OF THE SOUTH
NATIONAL INDEMNITY COMPANY OF MID-AMERICA
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
Per Person Per Accident Per Accident
Medical
Payments
Personal Injury
Protection
(where
applicable)
IF PHYSICAL DAMAGE COVERAGE
DESIRED - REFER TO FOLLOWING PAGE.
COMPLETE HIRED AND NON-OWNED
SUPPLEMENT IF COVERAGE DESIRED.
UNINSURED MOTORIST COVERAGE UNDERINSURED MOTORIST COVERAGE
Split Limits Split Limits
Bodily Injury Bodily Injury
Single Limit
Per Person Per Accident
Uninsured
Motorist
Stacking
Single Limit
Per Person Per Accident
Underinsured
Motorist Stacking
Yes No Yes No
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-5550 PA (12/2010) Special Types Application Page 1 of 5
All Risks, Ltd.
All Risks, Ltd.
2555 Kingston Road, #250
York, PA 17402
(717) 600-0417 Fax: (717) 441-3784
12. Does applicant have attendant=s E&O coverage? Yes No
13. What is the basis for driver(s) pay? Hourly
Trip Mileage Other, explain
14. Are drivers covered by workers compensation? Yes No Minimum years driving experience required
15. Are vehicles owner-driven only? Yes No Do you agree to report all newly hired operators? Yes No
16. Are drivers ever allowed to take vehicles home at night?
Yes No If yes, will family members drive? Yes No
17. Do you order MVRs 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
Emergency
Lights & Sirens
(Yes or No)
1
2
3
4
5
6
7
8
9
10
ALS Advanced Life Support
BLS Basic Life Support
BV Box Van
CP Cherry Picker
CV Cargo Van
F Flower Car
H Hearse
L Limo
LT Ladder Truck
MTA Medical Transportation
OR Off Road Auto
OV Other Van
PC Police Car
PPT Private Passenger Type
PT Pumper Truck
PU Pick Up
PV Passenger Van
RT Rescue Truck
SP Snow Plow
SS Street Sweeper
ST Semi-Trailer
T Truck
TA Transfer Ambulance
TR Trailer
TT Truck Tractor
UT Utility Trailer
WT Water Truck
Other, describe
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
18. Any loss payees? Yes No If yes, give name and address of mortgagee/loss payee for each vehicle
M-5550 PA (12/2010) Special Types Application Page 2 of 5
19. Is the transportation of people your primary business? Yes No Are vehicles leased to drivers? Yes No
20. Do you transport physically disabled individuals?
Yes No If yes, what percentage of the time %
21. Is our policy to cover all vehicles owned, operated or under lease to applicant? Yes No If no, explain
22. Number of Vehicles Owned by You: Ambulances Wheel Chair Vans Priv. Pass. Types Fire Trucks
Rescue Trucks Police Cars Hearses Limos Other
23. Number of Vehicles Leased to You: Ambulances Wheel Chair Vans Priv. Pass. Types Fire Trucks
Rescue Trucks Police Cars Hearses Limos Other
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
/ / / /
/ / / /
/ / / /
24. 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
25. Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No
If yes, explain
OPERATION INFORMATION
C
Complete only those sections relating to your operations.
AMBULANCE AND MEDICAL TRANSPORTATION VEHICLES
26. Do autos without lights and sirens have lifts, ramps or wheelchair tie downs? Yes No
If yes, show auto numbers from schedule
27. Do autos without lights and sirens have stretchers or gurneys? Yes No If yes, show auto numbers from schedule
28. How is gurney or wheelchair securely clamped for transportation?
29. Any autos operated 24 hours per day? Yes No If yes, show auto numbers from schedule
30. Is special driver training given? Yes No If yes, explain
31. What methods and qualifications are used for driver selection?
32. Are you the primary response unit for emergency (911) calls? Yes No
33. What percent of your ambulance dispatches are: Emergency (Code 3 or 4)?
% Non-Emergency (Code 1 or 2)? %
34. What procedure is required of drivers as they approach a red light?
35. Is your operation privately owned? Yes No
36. If privately owned, are you affiliated with a taxi or other transportation company? Yes No If yes, explain
DRIVER TRAINING PROGRAMS
37. Is operation part of a school curriculum? Yes No Is classroom instruction given? Yes No
38. Are all driver training autos equipped with dual brakes? Yes No If no, identify by auto number from schedule any that do not have dual brakes:
39. Are autos equipped with any other dual controls? Yes No If yes, explain
40. Is there any personal use of the automobiles? Yes No
FIRE DEPARTMENTS
41. Is your operation owned by a municipality? Yes No
42. What procedure is required of drivers as they approach a red light?
43. Is special driver training given? Yes No What methods are used for driver selection?
44. Are volunteers allowed to drive? Yes No If yes, is the same driver selection and special training used? Yes No
45. Do ladder truck drivers have special training? Yes No How many runs/calls are made per year per fire truck?
46. Is your operation volunteer? Yes No
FUNERAL DIRECTORS
47. Are hearses also used as ambulances? Yes No If yes, what percent is ambulance
%
48. Are limousines used for other purposes? Yes No If yes, explain and show percentage
M-5550 PA (12/2010) Special Types Application Page 3 of 5
LAW ENFORCEMENT AGENCIES
49. Are officers given training in defensive driving? Yes No Are officers given training in high-speed and pursuit driving? Yes No
50. What procedure is required of drivers as they approach a red light?
SECURITY PATROLS
51. Do vehicles operate 24 hours a day? Yes No Any special training? Yes No Are weapons carried? Yes No
52. Percentage of surveillance
% Patrolling %
53. Additional comments
FILING INFORMATION
54. Is an FHWA filing required? Yes No If yes, MC number
What authority do you have? Broker Common Contract
55. If you hold a broker’s license, identify name filed with FHWA, FHWA docket no. and receipts from brokerage operations
56. If you are an interstate regulated carrier, identify your registration or base state
57. Is an intrastate filing needed? Yes No If yes, show state and permit number
58. Show exact name and address in which permits are issued
59. Is MCS 90 endorsement needed? Yes No
60. Is our policy to cover all vehicles owned, operated or under lease to applicant?
Yes No If no, explain
61. Do you enter Canada? Yes No Do you enter Mexico? Yes No If yes, where
62. Have you ever changed your operating name? Yes No Do you operate under any other name? Yes No
63. Do you operate as a subsidiary of another company?
Yes No
64. Do you own or manage any other transportation operations that are not covered?
Yes No
65. Do you lease your authority?
Yes No Do you appoint agents or hire independent contractors to operate on your behalf? Yes No
66. Have you purchased, sold or applied for authority over the past 3 years?
Yes No
67 Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.)?
Yes No
68. Is evidence/certificate(s) of coverage required?
Yes No
69. Please explain any "yes" answer to Questions 62 through 68
70. 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
71. Do you barter, hire or lease any vehicles?
Yes No If yes, explain
72. Additional comments
M-5550 PA (12/2010) Special Types Application Page 4 of 5
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 Federal Highway Administration 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
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.
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.
M-5550 PA (12/2010) Special Types Application Page 5 of 5
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Completed 2 July 2020

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