Fillable Supplemental - Non Owned Auto36-9320

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Supplemental - Non Owned Auto36-9320

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NON-OWNED AUTO SUPPLEMENTAL APPLICATION
Applicant’s Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
SECTION I – APPLICANT INFORMATION
1.
Home Healthcare Facility
Hospice Organization
Meals on Wheels
Other (describe):
2.
Are there any company-owned vehicles?
Yes
No
If yes, please note that we will not write the non-owned auto without the scheduled vehicles.
3.
What is Applicant’s total number of:
Employees:
Volunteers:
Independent Contractors:
4.
Does Applicant run abuse and background checks on all drivers?
Yes
No
5.
During the most recent year, how many of the Applicant’s employees provided at home care?
6.
Does Applicant have a visiting nurse program?
Yes
No
7.
Total amount expensed in the previous fiscal period, as reported to the I.R.S. for employee
mileage reimbursement:
8.
If Applicant has visiting nurses or home care providers, is there a minimum age requirement?
Yes
No
9.
Estimated total number of employees/volunteers/independent contractors that use their own
vehicle for company business, not home care. (i.e. sales, delivery, mail pickup, bank deposits)
Employees:
Volunteers:
Independent Contractors:
10.
How often and for what purpose do employees/volunteers/independent contractors use their own
vehicle for company business? (i.e. daily, occasionally, never)
Employees:
Volunteers:
Independent Contractors:
11.
Does Applicant run MVRs on all employees:
At the time of hire?
Yes
No
Annually?
Yes
No
Randomly?
Yes
No
12.
Are Motor Vehicle Reports ordered on all non-employee drivers who may use a company vehicle?
Yes
No
13.
Does Applicant require all employees who use their own vehicles for company business to carry
personal auto insurance?
Yes
No
If yes, what limits are required? $
14.
Does Applicant obtain certificates of insurance or a copy of the declarations page from the
employees’ automobile insurer?
Yes
No
If yes, who maintains these records?
15.
Does Applicant confirm that the employee’s personal auto policy does not include an exclusion for
claims arising out of the course of driving if part of your profession?
Yes
No
16.
Does Applicant receive confirmation from employees that a preventative regular maintenance plan
is in place?
Yes
No
17.
Is there a process or procedure in place that requires an employee to notify the company if their
personal automobile policy has lapsed or been cancelled?
Yes
No
18.
Does Applicant require employees to complete a Defensive Driver Training Course?
Yes
No
19.
Does Applicant allow employees to operate a patient or client’s vehicle?
Yes
No
If yes, how does Applicant verify patient and/or client owned automobile liability coverage is in force?
If yes, does the Applicant require evidence of regular preventative maintenance?
Yes
No
20.
How many vehicles (cars, vans, trucks, or tractors) are hired, rented or borrowed each year?
Short-term leases (less than 6 months):
Short-term rentals (include airport rentals):
21.
Other than airport rentals, for what purpose are the hired vehicles used?
Non-Owned Auto Supplemental Application
Page 1 of 3
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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22.
Other than airport rentals, what is the total estimated cost for all hired vehicles for the most recent
fiscal period? $
23.
Who is providing primary automobile liability and automobile physical damage for the
hired/borrowed vehicles? (i.e. rental company, leasing firm, employee, insured, credit card)
24.
Does Applicant hire independent contractors to provide home care or other patient
services? N/A Yes No
25.
If home caregivers or visiting nurses are considered independent contractors, is there a
signed contract in place?
N/A
Yes
No
If yes, please provide a copy of the sample contract.
26.
Does the contract require the independent contractors to provide a certificate of insurance?
Yes
No
27. Does the contract require the independent contractors to carry a minimum of Automobile Liability
limit? Yes No
If yes, what is the limit? $
28.
Does the contract require the independent contractors to name our insured as an additional
insured?
Yes
No
29.
Is there a formal, written Fleet Safety Program in place?
Yes
No
30.
Are random drug tests conducted on employees?
Yes
No
31.
Is there a company policy on underage drivers using company vehicles?
Yes
No
32.
Are family members allowed to use the company owned vehicles?
Yes
No
33.
Does the agent or the Applicant include non-employee operators on the drivers list?
Yes
No
Non-Owned Auto Supplemental Application
Page 2 of 3
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
Clear Application
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE 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 THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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 THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA 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 OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Non-Owned Auto Supplemental Application
Page 3 of 3
© 2017 Philadelphia Consolidated Holding Corp.
09/2017
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