TEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF INSURANCE PROGRAM APPLICATION FOR VEHICLE LIABILITY INSURANCE

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TEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF INSURANCE PROGRAM APPLICATION FOR VEHICLE LIABILITY INSURANCE FOR TEXAS A&M FOREST SERVICE USE ONLY VFD CASE# COUNTY NOTE: ALL QUESTIONS MUST BE

1 TEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF INSURANCE PROGRAM APPLICATION FOR VEHICLE LIABILITY INSURANCE FOR TEXAS A&M FOREST SERVICE USE ONLY VFD CASE# COUNTY NOTE: ALL QUESTIONS MUST BE ANSWERED IN FULL IN ORDER TO RECEIVE CONSIDERATION. 1. Full name of Volunteer Fire Department: 2. Name of County in which Department operates: 3. Identify any unit of local government and/or fire district with which Department is associated: 4. Department mailing address: (Street or P.O. Box) (City) (Zip Code) 5. Department phone number: 6. Department fire station is: Inside city limits Outside city limits

2 7. Physical address of Departments fire station; (for stations with no street or highway address, state directions to station from nearest state highway). Attach separate page if necessary. 8. Department Chief: Daytime phone number: 9. Department contact person (if different from Chief): Daytime phone number: 10. Years Department in existence: 11. Area protected - (i.e. square miles, county, portion of county, etc.). Please be specific: 12. Population of area protected: 13. Department s federal tax (or tax exempt) identification number: 14. State whether or not Department is chartered by the State of Texas, incorporated, or both: (Please attach a copy of charter certificate or articles of incorporation to application). 15. Number of fire fighting personnel in the Department: 16. Number of fire fighting personnel authorized to drive Department fire fighting vehicles: 17. Please complete the attached Authorized Drivers List and submit with application.

3 18. Has any driver identified on the Authorized Drivers List received any traffic citations or been charged with Driving While Intoxicated within the last three (3) years? If so, state the nature of the citation and/or charge and the status of the same. Attach additional pages as necessary: 19. Number of fire fighting vehicles owned and/or operated by Department: (a) Brush Trucks: (b) Tankers/Tenders: (c) Pumpers: (d) Aerials: (e) Utility/Rescue: (f) Other (specify): TOTAL 20. Please fill out the attached Fire Fighting Vehicle Inventory with complete information requested as to each vehicle identified above. 21. If any fire fighting vehicle identified in your answers to the above questions is not owned by the Department, please state: (1) the entity holding title to each such vehicle, and (2) the nature of the relationship (e.g. lease) between the Department and said entity. Attach additional pages as necessary. 22. Does Department have formal fire fighting vehicle safety program in effect? If so, describe: 23. Has Department had any policy or coverage declined, canceled or non-renewed during the prior three (3) years? YES_ NO. If YES please explain in detail: 24. Departments current insurance carrier:

4 25. Amount Department is currently paying for vehicle liability insurance: 26. Number of fire fighting vehicle accidents in the last five- (5) years: 27. For each such accident referred to above, please state: (a) Date of accident: (b) Make and type of Department vehicle(s) involved: (c) Driver(s) of Department vehicle(s) involved: (d) Other vehicle(s)involved: (e) Location of accident: (f) Describe the accident: (g) State whether a claim was made: (h) Amount of claim: (i) State whether claim was paid: (j) Status of claim: Open Closed (k) Did accident result in a lawsuit against the Department? If so, please state: (1) Date suit filed: (2) Case style and cause number: _ (3) Outcome or status of suit: Attach additional pages as necessary for each additional accident. It is important to answer each question fully as to each accident.

5 28. Date you wish coverage to begin: *************************************************************************** WE, THE UNDERSIGNED VOLUNTEER FIRE DEPARTMENT, AFFIRM THAT THE ABOVE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE, WE UNDERSTAND THAT FALSE INFORMATION PROVIDED IN RESPONSE TO QUESTIONS IN THIS APPLICATION CAN RESULT IN THE IMMEDIATE TERMINATION OF COVERAGE. MOREOVER, WE AFFIRM THAT WE WILL COMPLY WITH THE SAFETY REQUIREMENTS FOR PARTICIPATION IN THE TEXAS VOLUNTEER FIRE DEPARTMENT MOTOR VEHICLE SELF-INSURANCE PROGRAM AS PROMULGATED BY THE TEXAS A&M FOREST SERVICE. *************************************************************************** Name of Volunteer Fire Department: Name of person authorized to contract on behalf of Department (please print): Title: Signature: Date: _ Please mail or fax application to: Texas A&M Forest Service Attn: Risk Pool Program P.O. Box 310 Lufkin, TX Phone: 936/ Fax: 936/

6 AUTHORIZED DRIVERS LIST DRIVERS NAME TEXAS DRIVERS LICENSE NUMBER DATE OF BIRTH VEHICLE AUTHORIZED TO DRIVE * NOTE: THIS LIST MUST BE KEPT CURRENT. ANY ADDITIONAL DRIVERS CAN BE ADDED TO THE AUTHORIZED LIST BY CALLING THE TEXAS FOREST SERVICE. ON NEW DRIVERS THIS MUST BE DONE BEFORE OPERATION OF AN INSURED VEHICLE.

7 FIRE FIGHTING VEHICLE INVENTORY YEAR MAKE AND TYPE VEHICLE LICENSE NUMBER VEHICLE IDENTIFICATION NUMBER

8 SAFETY STANDARDS FOR FIRE PROTECTION VEHICLES COVERED BY THE VFD MOTOR VEHICLE SELF INSURANCE To meet eligibility criteria for approval and participation under the Texas A&M Forest Service VFD Motor Vehicle Self-Insurance Program, drivers and vehicles shall meet or exceed the following requirements: 1. Drivers of fire apparatus shall be at least 18 years of age and have a valid driver's license to operate the vehicle/s. 2. There shall be documentation of the driver's license for any individual who drives or may be required to drive an insured vehicle. 3. Name, date of birth and license number of all authorized drivers must be submitted to Texas A&M Forest Service before operation of an insured vehicle. 4. Drivers of fire apparatus must be thoroughly trained and the training documented. 5. All drivers of insured vehicles shall abide by State traffic laws. 6. Each insured organization shall have a written policy that sets forth speed limits for its vehicles on emergency runs. This policy should state that at no time would a vehicle be driven in such a manner as to endanger life or property. 7. The volunteer fire department shall have a policy prohibiting the operation of insured vehicles while under the influence of alcohol or controlled substances. 8. All emergency vehicles shall be provided with audible and visible warning devices. These devices shall be kept in proper working order and utilized on emergency runs. 9. Every insured fire vehicle shall have a current State safety inspection sticker displayed on the front windshield. 10. Wheel chocks must be used for the rear wheels of aerial ladder apparatus to help prevent the apparatus from slipping. 11. There shall be a preventive maintenance program in place to ensure that all emergency vehicles are maintained in a safe condition. The following items are suggested safety areas that should be checked: (a) Visible and audible warning signals (b) Lighting system (c) Tires (d) Steering (e) Brake system air tanks (f) Brake fluid (g) Windshield wipers (h) Rear view mirrors This list is not meant to be a complete listing, but only a guide to set up your own program.

9 12. Applications for insurance coverage, pursuant to SB 1323, are subject to review by the Texas A&M Forest Service. The review may include a physical inspection of the vehicles and related records. 13. Insured volunteer fire departments are subject to random safety and loss prevention inspections of equipment for as long as they choose to participate in the selfinsurance pool program. 14. Non-compliance with safety standards as required by the Texas A&M Forest Service could result in a denial to participate in the program or cancellation of coverage.

APPLICATION FOR VEHICLE LIABILITY INSURANCE

FOR INTERNAL USE ONLY Case: Start Date: APPLICATION FOR VEHICLE LIABILITY INSURANCE Texas Volunteer Fire Department Motor Vehicle Self Insurance Program Name of Fire Department: Physical Address: (Street