LIMO SUPPLEMENTAL APPLICATION

Transcription

1 Buschbach Insurance Agency, Inc W. 95 th Street P.O. Box 5000 Oak Lawn, Illinois Phone: (708) Fax: (708) rthwest Point Blvd. Suite 300, Elk Grove Village, IL LIMO SUPPLEMENTAL APPLICATION It is specifically represented that the statements in this application are true and correct. It is further understood that the representations in this application have been made to American Country Insurance Company (the Company) and the Company is relying upon the truthfulness of the statements in making the decision to accept this risk. ANY MISREPRESENTATIONS OF STATEMENTS MAY VOID THE POLICY GENERAL INFORMATION Name Insured: Detailed Description of your operations: FEIN# or SS#: Association Memberships: TLPA NLA ne Other (describe) Are any filings required? If yes provide ICC / PUC docket #: How many years has this organization been under the present name? List all subsidiaries: Years in business: If you are a new venture, have you ever driven / been associated with any other passenger transportation company? If yes, give name, address, and dates: What % of business is dispatched? Are dispatch services shared with any other company? Please provide names of organizations in which you have current contracts to provide transportation services: Radius of operation (total 100%): 0-50 miles miles Over 200 miles List the cities in which you have operating authority: Major Metropolitan area(s) served: What percentage of your trips are (total 100%) Airport Corporate School n-emergency medical Disabled/Handicapped Scheduled shuttle service Other (please explain) LIMO SUPP

2 Vehicles used for any purpose other than passenger transportation for hire? If, explain: Do you have a formal safety program? VEHICLE INFORMATION How many vehicles do you own? How many shifts do you run with you vehicles? Are all vehicles both titled and registered to the named insured? ***IF NO, THERE MUST BE A LEASE AGREEMENT BETWEEN THE NAMED INSURED AND THE VEHICLE OWNER*** Are all vehicles titled / licensed in the State in which they operate? ***PLEASE PROVIDE A COPY OF ALL VEHICLE REGISTRATION VERIFYING OWNERSHIP OF SCHEDULED VEHICLES. IF APPLICABLE, PROVIDE LEASE AGREEMENTS ON ALL VEHICLES LISTED ON THE APPLICATION / POLICY. THE POLICY WILL ONLY INCLUDE THOSE VEHICLES WHERE THE NAMED INSURED OWNS THE PERMITS / MEDALLIONS.*** Do you subcontract work to others? Are certificates of insurance obtained? What limits of liability do you require? (Equal to / greater than current coverage) $ Do you have a written vehicle maintenance program? Vehicles are serviced on the following regular basis: 3,000 miles Monthly Semi-annually Other (explain) Who provides the maintenance your vehicles? Are daily or pre-trip inspections made to the vehicles? How often are maintenance records reviewed by management? How many plates are you registered to operate? At which airport(s), if any, do you pick up or deliver? Are any of your taxis equipped with: Lift out / Pull out ramps? Mechanical lifts? Wheelchair passenger / patient safety restraint system? Vehicle wheelchair securing system? Ambulatory passenger / patient safety restraint system? LIMO SUPP

3 DRIVER INFORMATION Driver hiring criteria: Written application? Do you review MVRs before hiring? Any age requirements for drivers? If yes what are they? Do you have a driver training program? Do you hold regular safety meetings? If yes, how often? Are drivers trained to assist elderly / handicapped passengers? Do you have a drug testing policy? Briefly Describe: Is a post accident drug testing policy in place? Describe: Are your drivers employees or independent operators? Employees Independent operators Do you provide Workers Compensation Coverage for your drivers? Do the drivers take the vehicles home? If yes, any of the vehicles used by family members? If yes, provide name, date of birth and drivers license number: Do you have a driver incentive program? If yes, describe: Current # of drivers: In the past year how many drivers did you add: replace: How often are driver MVRs checked? Annually Semi-Annually Quarterly After Accident Are MVRs obtained and reviewed prior to hiring new drivers? Are accident investigation and review procedures, including records, maintained? Do the review procedures include driver disciplinary procedures? If yes, explain: The completion of this supplemental application creates no express or implied obligation on the part of the company or its manager to offer a quotation or provide insurance. LIMO SUPP

4 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (t applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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. NEW YORK: ANY PERSON WHO KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE 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. OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICTION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. OKLAHOMA: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH THE INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. PENNSYLVANIA: 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. AUTO: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND THE PAYMENT OF A FINE OF UP TO $15,000. Signature of Insured Title Date Producer s Signature Date LIMO SUPP

5 COMPLETE SUBMISSION REQUIREMENTS: 1. This supplemental application, signed by the insured. 2. Description of why the account is an opportunity for ACIC and what we can do to satisfy your needs. 3. Current applicable ACORD Applications for coverages desired. Vehicle schedule should include 17 digit VIN #, radius, length of stretched vehicles and number of passengers. 4. Minimum of 4 years of hard copy loss runs valued within the last 60 days. Include details on claims over $10, Current drivers list and MVRs. Drivers list must include family members who have access to company vehicles. 6. Provide details regarding the changes in fleet size over past four years. Year Number of Units Premium Per Unit LIMO SUPP