Tow Truck Supplement
Policy Term From: To
This Supplement is a part of the Application and will be relied upon
by the Company as an integral part of the Application.
IN TOW COVERAGE (To provide coverage on nonowned autos* towed by rollbacks or wreckers)
1) Limit Per Vehicle $ Deductible Per Auto G 500 G 1,000 G Other:
2) Number of Scheduled Tow Trucks:
3) Are Tractor/Trailer Combinations towed? G Yes G No
4) Maximum # of Units (Including Trailers) Towed/Hauled by any one Power Unit:
*If hauling owned units, cargo applies.
STORAGE LOCATION (Specified Causes of Loss and Collision)
1) Limit of Liability Per Location: $ Deductible Per Auto G 500 G 1,000 G Other:
2) Number of Locations:
3) Maximum Number of Customers’ Autos Stored:
4) Maximum Limit of any one Covered Auto: $
5) Are Customers’ cars stored overnight? G Yes G No
6) Is yard fenced and lighted? G Yes G No
7) Where are keys to customers’ cars kept?
AUTO REPOSSESSORS (Only fill out if repossessions are performed)
1) What % of towing operation involves repossession: %
2) How are vehicles repossessed? Describe procedure in detail.
3) Are any vehicles driven away? G Yes G No If yes, list # of repo plates and plate number:
List drivers:
Is physical damage coverage requested on vehicles driven away? G Yes G No Limit: $
Deductible Per Auto G 500 G 1,000 G Other:
4) Are any independent contractors/subcontractors used? G Yes G No
5) How many vehicles did you repo last year? By Tow Truck
By Drive Away Subcontractor
6) Estimate % of repos that are: Private Passenger Autos %
Light Commercial Trucks
%
Heavy Commercial Trucks
%
Commercial Trailers
%
Other (Describe)
%
100 %
7) Estimate % of repos that are: Voluntary
% Involuntary %
8) Does applicant or any employees carry firearms? G Yes G No
9) Are Police notified? G Yes G No Do they ever accompany you on a repossession? G Yes G No
If yes, before or after the fact?
10) List primary customers for which you repossess:
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
4367c VA (11/2003) Tow Truck Supplement Page 1 of 1
Atlantic Specialty Lines, Inc.
(800)368-2095 FAX: (804)320-7280
