Fillable Transportation Services Program Supplemental Application (RT Specialty)

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Transportation Services Program Supplemental Application (RT Specialty)

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The Transportation Services Program Supplemental Application (RT Specialty) form is 4 pages long and contains:

  • 2 signatures
  • 9 check-boxes
  • 123 other fields

Country of origin: US
File type: PDF

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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
www.scottsdaleins.com
Transportation Services Program Supplemental Application
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent:
Phone:
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"
1. Type of transportation service provided: Taxi Limo Other
If other, nature of operation:
2. Sexual and/or Physical Abuse Coverage Limits: $25,000 Per Claim/$50,000 Aggregate None
3. Number of vehicles per type (owned or contracted):
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
GLS-APP-68s (10-12) Page 1 of 4
Submit Application
10. 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:
11. Is liquor served or provided by applicant or subcontractor? ............................................................... Yes No
If yes, explain:
12. Does applicant provide or plan to provide any of the following services?
Air transportation services ......................... Yes No
Pedicabs ..................................................... Yes No
Ambulance/Emergency transportation
services .....................................................
Yes No
If yes, are pedicabs used on public
streets in metropolitan areas? ................
Yes No
City bus ...................................................... Yes No
Prisoner transportation services ................. Yes No
Drivers provided for customers’ vehicles .. Yes No
Railroad transportation services ................. Yes No
Emergency medical treatment................... Yes No
School bus .................................................. Yes No
Funeral transportation services ................. Yes No
Tour/Sightseeing agencies ......................... Yes No
Motorhome or Recreational vehicles ......... Yes No
Transportation of goods or commodities .... Yes No
Pedal buses (people powered buses) ....... Yes No
Water transportation services ..................... Yes No
13. 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:
14. Does applicant have other business ventures for which coverage is not requested? ....................... Yes No
If yes, explain and advise where insured:
15. 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 Nebraska, Oregon and Vermont.
GLS-APP-68s (10-12) Page 2 of 4
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 in the third degree.
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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 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.
GLS-APP-68s (10-12) Page 3 of 4
FRAUD WARNING APPLICABLE IN THE STATE OF 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 also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such 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:
GLS-APP-68s (10-12) Page 4 of 4
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Transportation Services Program Supplemental Application (RT Specialty)

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Completed 13 December 2020

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