Fillable ve-Away Application Dri Individual/Proprietorship Partnership Corporation Other Business (Risk Placement Services, Inc.)

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ve-Away Application Dri Individual/Proprietorship Partnership Corporation Other Business (Risk Placement Services, Inc.)

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The ve-Away Application Dri Individual/Proprietorship Partnership Corporation Other Business (Risk Placement Services, Inc.) form is 3 pages long and contains:

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  • 24 check-boxes
  • 271 other fields

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File type: PDF

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Dri
ve-Away Application
COLUMBIA INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY OF THE SOUTH
NATIONAL INDEMNITY COMPANY OF MID-AMERICA
Policy Term From:
To:
1. Name (and "dba")
 Individual/Proprietorship Partnership Corporation Other Business phone number
2. Mailing address City State Zip
3. Premises address City State Zip
4. Person to contact for inspection (name and phone number)
5. Have you ever had insurance with one of the companies listed at the top of this page? Yes No
If
yes, policy
number(s)
Effective date(s)
DESCRIPTION OF OPERATIONS
6. Describe business
Years experience New Venture? Yes No
7.
Is this your primary business?
Yes No If no, explain
8. Have you ever filed for bankruptcy? Yes No If yes, when Explain
9. Gross receipts last year Estimate for coming year Business for sale? Yes No
10.
Do you operate in more than one state?
Yes No If yes, list states
11. Do you operate over a regular route? Yes No If yes, show towns operated between
LIABILITY COVERAGE – Complete for desired coverages by indicating limits of insurance.
LIABILITY
PHYSICAL DAMAGE
Split Limits Deductibles
Bodily Injury
Property
Damage
Combined Single
Limit BI & PD
Per Person Per Accident Per Accident
Medical
Payments
Personal
Injury
Protection
(where
applicable)
Comprehensive
Spec. C of
Loss
Collision
Maximum
Vehicle
Value
UNINSURED MOTORIST COVERAGE
Split Limits
Bodily Injury
Property Damage
Single Limit
Per Person Per Accident Per Accident
DRIVER INFORMATION – If additional space is needed, attach separate listing.
Driver's Licenses
Experience
Driver's Name Date of Birth
State Number
Class/Type
(i.e. CDL)
Years
Licensed (in
class/type)
Type of Unit
(bus, van,
truck, tractor,
etc.)
No. of
Years
1.
2.
3.
4.
5.
DRIVER INFORMATION (Continued) – If additional space is needed, attach separate listing.
Accidents and Minor Moving Traffic
Violations in Past 5 Years
Major Convictions
(DWI/DUI, hit & run, manslaughter, reckless,
driving while suspended/revoked, speed contest,
other felony)
No. Years
Previous
Commercial
Driving
Experience
Date of Hire
No. of
Accidents
Date(s)
No. of
Violations
Date(s) Describe Conviction Date(s)
Employee (E)
Ind. Cont. (IC)
Owner/Op. (O/O)
Franchisee (F)
1.
2.
3.
4.
5.
PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.
M-5545 DE (12/2010) Drive-Away Application Page 1 of 3
12. Are drivers covered by workers compensation? Yes No If yes, name of carrier
13. Minimum years driving experience required
14. Are drivers ever allowed to take vehicles home at night? Yes No If yes, will family members drive? Yes No
15. Do you order MVRs on all drivers prior to hiring?
Yes No Driver's maximum driving hours daily weekly
16. Do you agree to report all newly hired operators?
Yes No
17. What is the basis for driver(s) pay?
Hourly Trip Mileage Other, explain
LOSS EXPERIENCE – Provide prior insurance carriers information for past full three years.
Policy Term Premium Total Amount Claims Paid & Reserves
From To
Insurance Company Name
No. of Motor
Powered
Vehicles
No. of
Accidents
Liab Phys Dam BI PD Comp/Coll Other
/ / / /
/ / / /
/ / / /
18. Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage
sought in this application?
Yes No
If yes, provide complete details
19. Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No If yes, date and why
DRIVE-AWAY INFORMATION
20 Types of units driven away and percentages of each
21. Percentage of the time you drive away new units % Used units %
22. If physical damage coverage is desired, what is the average value per unit?
What is the maximum value per unit?
23. How are you paid? By Miles By Trip
24. Average rate you are paid per mile
Per trip
25. Total number of full-time drivers Total number of part-time drivers
26. Do you require insurance filings? State FHWA If FHWA filing, please provide MC number
27. How is return trip handled? _
28. Is delivery made with one unit towing another unit? Yes No Do you permit drivers to tow their own vehicles? Yes No
Do you haul away vehicles?
Yes No Do you use any of the following: Fifth Wheel Tow Bars  Reese Hitches  Ball Hitches
29. If towing a vehicle for return transportation, how often is this done?
30. Maximum radius one-way Average radius one-way Estimated total annual mileage
31. Average total number of trips per week Do you deliver vehicles both ways? Yes No
32. Cities and states where units are picked up
33. List city and state destinations
34. List clients
35. Any operations other than drive-away service? Yes No If yes, explain
Plate Information
36. Are you required to use plates? Yes No Do you use your own plates exclusively? Yes No Total number of plates
What type of plates do you use? Transporter IRP Other
37. How many plates are required to be attached to each unit drive away?
On average, how many of your plates are attached to drive-away vehicles at any given point?
38. How are plates returned to you? Average number of days before plates are returned
39. List identification number for each plate
40. Are all plates owned to be insured this policy? Yes NoIf no, explain
Also, if no, number of operators used Do operators have written contracts with you? Yes No ATTACH COPY OF CONTRACT.
Private Passenger Drive-Away
41. Do you drive-away sports cars or luxury type units? Yes No
If yes, list unit model(s)
42. Do you tow a second client-owned vehicle? Yes No
Bus Drive-Away
43. Percentage of time units with the following seating capacities are driven away: Under 20 % 21 and Over %
Truck/Tractor Drive-Away
44. Percentage of time each unit type is driven away: Trucks
% Tractors % Tractors and Trailers %
45. If trucks, percentage of each GVW driven away: 0-20,000 lbs
% 20,001-45,000 lbs % 45,001+ lbs %
46. Do you piggyback?
Yes No What percentage of time do you piggyback? %
47. What percentage of your piggyback operation is 1 up?
% 2 Up? % 3 Up? %
M-5545 DE (12/2010) Drive-Away Application Page 2 of 3
MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the
policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is
acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may
not accept any funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false,
the Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be
attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that
endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the
Applicant or any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business
background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional
information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
Will premium be financed? Yes No If yes, with whom
Witness Applicant's Signature Date
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE
Is this direct business to your office?
If not, explain
Is this new business to your office? If not, how long have you had the account?
How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Please quote Please bind at earliest possible date and issue policy
Please issue policy effective
Coverage was bound by
(Time and Date Bound by General Agent) (Name of Person in Company General Agency's Office Binding Coverage)
Applicant's Representative's Name and Address Phone No.
M-5545 DE (12/2010) Drive-Away Application Page 3 of 3
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ve-Away Application Dri IndividualProprietorship Partnership Corporation Other Business (Risk Placement Services, Inc.)

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Completed 23 November 2020

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