Fillable Tow Truck Operators Supplemental Application (Colonial General Insurance Agency, Inc)

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Tow Truck Operators Supplemental Application (Colonial General Insurance Agency, Inc)

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CA-APP-16 (1-13) Page 1 of 4
P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (800) 332-9285
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:
10. Do employees use any vehicles for personal use? ............................................................................... Yes No
CA-APP-16 (1-13) Page 2 of 4
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
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
Flatbed
Hook & Chain
Wheel Axle
Integrated
CA-APP-16 (1-13) Page 3 of 4
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.
FRAUD WARNING: 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. (Not applicable to Nebraska, Oregon or Vermont).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a
fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
CA-APP-16 (1-13) Page 4 of 4
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
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)
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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Tow Truck Operators Supplemental Application (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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