Fillable TOW TRUCK OPERATORS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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TOW TRUCK OPERATORS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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CA-APP-16 (1-17) Page 1 of 3
National Casualty Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
TOW TRUCK OPERATORS SUPPLEMENTAL APPLICATION
(Complete in addition to the Commercial Automobile Application)
Applicant’s Name:
1. Indicate type of operations conducted:
Towing only Body Shop/Tow Auto Repair/Tow Salvage/Tow Sales of Automobiles
Other—Describe:
2. Number of employees hired in the last twelve (12) months:
3. Percentage of Towing:
Dealerships: ..................................................
%
Emergency Scanners: ..................................
%
Emergency Road Service: ............................
%
Garages: .......................................................
%
Impound: ....................................................... %
Non-Consent Towing: ................................... %
(Abandoned Vehicle, Illegal Parking, etc.)
Municipal Contracts: .....................................
%
Motor Club Contracts: ...................................
%
Police Rotation: .............................................
%
Rental Car Contracts: ...................................
%
Repossession: .............................................. %
Voluntary: ............................................... %
Involuntary: .............................................
%
Telephone Requests:.................................... %
Other: ............................................................
% Describe:
4. Type of Vehicles Towed:
Private Passengers/Pick-ups: .......................
% Heavy/Extra Heavy Truck-Tractors/Trailers:
%
Motor Homes: ............................................... %
Non-Auto: ..................................................... %
(Watercraft, Heavy Equipment, etc.)
Specialized: ..................................................
% Describe:
5. Number of dealer/transporter/repo tags:
6. Are passengers allowed to ride in your vehicle? ................................................................................... Yes No
7. Are customers allowed to ride in their vehicle while being towed? .................................................... Yes No
8. Do you operate on a 24/7 basis? .............................................................................................................. Yes No
9. Any guaranties, warranties, hold harmless or waiver of subrogation agreements? ......................... Yes No
If “Yes,” explain:
CA-APP-16 (1-17) Page 2 of 3
10. Do employees use any vehicles for personal use? ............................................................................... Yes No
11. Have all drivers received certification from an accredited school, such as AAA, CTTA, etc.? ........ Yes No
12. Are vehicles/equipment loaned or rented to others? ............................................................................ Yes No
13. Are vehicles equipped with alarms? ....................................................................................................... Yes No
14. Vehicle Schedule
Include value of permanently attached wrecker equipment to the value of each vehicle for physical damage coverage.
Unit
No.
Year/Make/Model/VIN Type of Wrecker GVW
No. of
Vehicles
Towed
In-Tow Limit
Desired
Avg/Max
Radius
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
Flatbed
Hook & Chain
Wheel Axle
CA-APP-16 (1-17) Page 3 of 3
Flatbed (Rollback or Slide)—The entire back of the truck is fitted with a bed that can be hydraulically inclined and moved
to ground level, allowing the customer’s vehicle to be placed on it under its own power or pulled by a winch.
Hook and Chain (Sling or Belt Lift)—Chains are looped around the vehicle frame or axle, which is drawn aloft by a
boom winch to rest against a pair of heavy rubberized mats so the customer’s vehicle can be towed on its other axle.
Wheel-Lift (Axle Cradling)—A large metal yoke is fitted under the front or rear wheels to cradle them, drawing the front
or rear end of the vehicle clear of the ground by a pneumatic or hydraulic hoist so it can be towed. This apparatus gener-
ally picks up the drive wheels of the vehicle (i.e. the front wheels if it is front wheel drive, the rear wheels if it is rear wheel
drive) touching only the tires.
Integrated (Snatcher or Repo Truck)—Boom and wheel-lift integrated into one unit. Used predominantly to repossess
vehicles or move illegally parked vehicles. Most have controls for the apparatus inside the cab of the tow truck to make
quick pickup possible without the inconvenience of exiting the truck to hook up the vehicle.
Refer to the application form for State Fraud Warnings.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
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TOW TRUCK OPERATORS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 7 February 2021

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