Fillable Transportation Services GL APP 68s 6-18 Fillable

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Transportation Services GL APP 68s 6-18 Fillable

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GL-APP-68s (6-18) Page 1 of 5
TRANSPORTATION SERVICES PROGRAM SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Type of transportation service provided: Taxi Limo Other
If other, describe nature of operation:
2. Sexual and/or Physical Abuse Coverage Limits: $25,000 Per Claim/$ 50,000 Aggregate
$50,000 Per Claim/$100,000 Aggregate
None
3. Number of vehicles per type (owned or leased/rented):
Type Passenger Car
Limo Van Bus Pedicab Other
Number
If other, describe:
4. Does any vehicle have capacity in excess of fifteen (15) passengers? .............................................. Yes No
If yes, advise type of vehicle and number of passenger seats:
5. Is there an established vehicle maintenance program?........................................................................ Yes No
6. Radius of operation (in miles): .................................................................................................................
7. Does applicant have an ICC or PUC filing? ............................................................................................ Yes No
8. Are state or local business licenses required? ...................................................................................... Yes No
9. Are background checks or investigations performed and MVRs obtained as part of the pre-
employment criteria? ................................................................................................................................ Yes No
GL-APP-68s (6-18) Page 2 of 5
10. Does applicant have common ownership with, contracts with or provides services for an as-
sisted living, convalescent or nursing home facility? ........................................................................... Yes No
11. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work: ...................................................................................................... $
c. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
If yes, minimum General Liability limits required:.................................................................................. $
d. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
e. Is applicant included as additional insured on all subcontractors’ policies? ......................................... Yes No
f. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
12. Is liquor served or provided by applicant or subcontractor? ............................................................... Yes No
If yes, explain:
13. Does applicant provide or plan to provide any of the following services?
Air transportation services? ......................................................................................................................... Yes No
Ambulance/Emergency transportation services? ........................................................................................ Yes No
Cadaver (corpse) transport? ........................................................................................................................ Yes No
Carriage rides? ............................................................................................................................................ Yes No
City buses? .................................................................................................................................................. Yes No
Drivers provided for customers’ vehicles? ................................................................................................... Yes No
Emergency medical treatment? ................................................................................................................... Yes No
Funeral transportation services? ................................................................................................................. Yes No
Jeep Tours? ................................................................................................................................................. Yes No
Motorhomes? ............................................................................................................................................... Yes No
Party buses? ................................................................................................................................................ Yes No
Pedal buses (people powered)? .................................................................................................................. Yes No
Pedicabs? .................................................................................................................................................... Yes No
If yes, are pedicabs used on public streets in metropolitan areas? ...................................................... Yes No
Prisoner transportation services? ................................................................................................................ Yes No
Pub crawls (pedal bus or motorized)? ......................................................................................................... Yes No
Railroad transportation services? ................................................................................................................ Yes No
Recreational vehicles?................................................................................................................................. Yes No
Ride sharing services (i.e., Uber and Lyft)? ................................................................................................ Yes No
School buses? ............................................................................................................................................. Yes No
Tour/Sightseeing agencies? ........................................................................................................................ Yes No
Transportation of goods or commodities? ................................................................................................... Yes No
Water transportation services? .................................................................................................................... Yes No
14. Does applicant offer marijuana/cannabis tours in the state of AK, CO, OR and/or WA? .................. Yes No
GL-APP-68s (6-18) Page 3 of 5
15. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
16. Does applicant have any other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
17. Automobile Policy Information (include copy of vehicle schedule):
Policy Number:
Insurance Carrier:
Limits of Liability: ......................................................................................................................................... $
Expiration Date: ...........................................................................................................................................
This application does not bind the applicant nor the Company to complete the insurance but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
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 in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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 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.
GL-APP-68s (6-18) Page 4 of 5
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.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
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 VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
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 OTHER THAN AUTOMOBILE 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 shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
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.
GL-APP-68s (6-18) Page 5 of 5
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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Transportation Services GL APP 68s 6-18 Fillable

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Completed 21 July 2020

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