If different from business address, complete 5. and 6. M-4003b (12/92) 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 1. 2. 3. 4. 5. 6. 7. 8. 9.
NATIONAL INDEMINITY COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY COLUMBIA INSURANCE COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA WESCO-FINANCIAL INSURANCE COMPANY
Applicant's Name Applicant is:
Name of Legal Owner of Business: (a)
(b) (c)
Address where vehicles are garaged Mailing Address
Person to Contact:
For Inspection (Name and Phone Number)
For Accounting Records (Name and Phone Number) Insurance is desired from:
Is this a new operation?
Do you now or have you ever had an interest in another transportation or leasing company? If yes, explain
How long has this business operated under the above name? Has this business ever operated under any other name? Current management has controlled the business since (a) Name (b) (c) (d) (a) (b)
Has insurance ever been declined, cancelled or nonrenewed?
Do you plan on expanding or adding additional vehicles during the coming year? Are any lessors or others intended to be additional insureds?
If yes, list:
(a) (b)
Business Address
Is this location within the corporate city limits? Business hours from
List major owners/shareholders/management:
What is estimated net worth of the business? Gross receipts last year?
Percent of receipts from referral commissions?
Have you ever filed or are you contemplating filing for reorganization or bankruptcy? (month and year) and explain:
Have you been released from reorganization or bankruptcy?
Is this your primary business?
If no, what is your primary business? (Describe) Name Individual (Number) (Number) Yes No Partnership to
Is your operation currently for sale?
Years with Company
(Street)
(Street)
Vehicle #
Corporation
Estimate for coming year? Yes
If yes, provide previous name and address: (General Agent)
LIMOUSINE APPLICATION
SECTION 1 - General Information
(City)
(City)
SUBMIT TO:
19
If yes, date and why?
(yr) and has been in public transportation business since
Date released No
ALL RISKS, LTD.
to % of Ownership Address (County) (County) Yes If yes, explain: No yearsIf yes, show date Seasonal in nature? Yes (State) (State) Relationship/Interest No Net Worth 12. (a) (b) 16. 17. 18. 19. Yes Yes Yes Yes Yes Yes Yes Yes 19 ARF2275 (Zip Code) (Zip Code) No No No No No No No No (yr)
21. Complete for desired coverages: 20. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. Combined CSL (a) (b)
Loss Payees (applicable only to Specified Causes of Loss and Collision Coverage)
Largest city entered within your radius of operation: Number of hours per day limo is available:
Do you belong to any local or state limo association?
Do you have safety belts installed in your limo for passengers?
Does your State law require you to have safety belts installed for passengers? Are alcoholic beverages available in the passenger compartment?
If yes, have all proper State and City licenses been obtained? Are vehicles equipped with fare box or meter?
Are vehicles equipped with 2 way radios?
Do you share dispatch services with any other company or entity? If yes, explain:
Do you share ride? If yes, explain:
Do you ever transport unscheduled passengers? If yes, explain:
Are prices or rates posted? Are odometer readings made?
If yes, are charges based on miles traveled? Minimum number of hours rented?
Are vehicles leased to drivers?
Do all clients have prearranged reservations? If no, explain:
Percent of business from hotels funeral directors
Percent of gross receipts from overflow business of other livery services subcontracted to you: Are services provided to other livery services under written contract?
If yes, are you required to provide your own liability insurance?
Percent of gross receipts from your overflow business subcontracted to other livery services: Are services provided by other livery services or franchises under written contract?
If yes, do you require them to provide their own liability insurance?
BI & PD
Unit #
Do you long term lease your vehicle to another? their address
Does lease agreement require:
Name and address of Loss Payee
Per Person BI
other
Per Accident Per Accident
Explain airport
LIABILITY LIMITS DESIRED
(1) You to provide or hire the driver? (2) Drivers to be your employees? (3) You to indemnify the lessee?
PD
Minimum charge?
CSL
Yes
special occasion
SECTION 2 - Limo Operations
Per PersonNo
U.M.
If yes, complete showing person or organization and
Per Accident travel agencies Payments Medical PIP % To franchises: tour operators Causes of Loss
Physical Damage Deductible Specified (1) (2) (3) 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 36. 37. 40. 42. ARF2275B Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Collision % No No No No No No No No No No No No No No No No No No No No No No
43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62.
*Major violations include: DWI/DUI, license suspensions for moving violations, felonies, hit and run, eluding an officer, reckless/negligent operation of a vehicle. Accidents include all At-Fault accidents.
Minor violations include any moving violation other than Major violations/Accidents as defined above.
Has applicant or any driver had his driver license revoked or suspended within the last 3 years? If yes, explain:
Are uniforms required?
Do drivers operate the same vehicle each day?
Are new drivers required to ride with experienced driver? Is previous chauffeur experience required?
Is driver training provided?
Have any drivers had any special training in techniques for eluding kidnappers and terrorists? Are drivers ever allowed to take vehicles home at night?
If yes, will family members be allowed to drive? Driver selection:
[ ] written application
[ ] review MVR. Pre-employment [ ] [ ] written test
[ ] background check
Current number of full time drivers: total
During the last 12 months, how many full-time drivers did you hire? How many part-time/seasonal drivers did you hire?
How many owner/operators or leased drivers were used? How many different owner/operators in last 36 months? Driver's pay scale is (check all that apply):
Driver's maximum hours: Driving
Do you provide Workers' Compensation for ALL drivers? Is equipment owner-driven only?
If no, are any drivers considered independent contractors? If yes, explain Driving standards: (a) (b) (c) (d) (e) Drivers Other, explain:
Minimum driving age? Minimum driving experience?
How often do you reorder MVR?
Driver's Name
Maximum number driving violations
Do you have a disciplinary program in place in dealing with problem drivers? If yes, explain
(Complete for all drivers - If not sufficient space add by separate sheet) Date of Birth On duty Social Security No. years old daily, daily,
Driver License No. Union
years.
or Post-employment [ ]
Maximum number of accidents
SECTION 3 - Driver Information
over 65 weekly weekly Non-Union Licensed Where State ExperienceChauffeur Previous No. Yrs Date of Hire Hourly [ ] physical exam [ ] road test [ ] other - specify (F or P) Full or terminate? under 25 Time terminate? Part Married (Y or N) Co. Emp. Operator chises (F) Owner/ (O/O) Fran-Trip (C) 43. 44. 45. 46. 47. 48. 49. 50. 59. 60. (d) Major No. of Violations in Last 3 years * Mileage Accs Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes ARF2275C Minor No No No No No No No No No No No No No
AK AL AR AZ CA CO CT 63. 64. 65. 66. 67. 68. 69. 70. 71. 72.
73. PHYSICAL DAMAGE (complete when physical damage coverage to be afforded)
1 2
Check Box 1 if you either applied for or currently hold operating authority or permits and
(a) (b)
Do you appoint agents/franchises to operate on your behalf? Do you lease your authority?
Do you operate under any other name?
Do you operate as either a parent or a subsidiary of another company?
Do you have agreements with other livery services or franchises for the interchange of equipment or transportation of passengers? If yes, attach a copy of current agreements and complete the following:
(a) (b) (c) (d)
Is evidence of coverage required?
Lease information for lease terms under 6 months: Do you hire or lease any vehicles? If yes, attach a copy of all current lease agreements and complete the following:
Do you own or operate any vehicles not listed on this application?
If yes, does applicant have other commercial liability insurance in force? If yes, give company, number of vehicles covered, limits and details:
From Others To Others
Do you have an ICC Permit? Are state filings required?
Show exact name and address in which permits are issued
With whom has such agreement(s) been made Is there a hold harmless in the agreement(s)?
Do the parties named in agreement carry automobile liability insurance? If yes, name of insurance company
Under whose permit does each of the parties to the agreement(s) operate?
Schedule of All Locations LEASE Entity/DBA Name of DC DE FL GA IA ID IL 1 2 With Driver Without If yes, to whom
Show states where needed and docket numbers
(Terminal, Garage, Storage, ICC/PUC
Number
If yes, Docket Number
Type of Facility
If yes, list to whom and why:
IN KS KY LA MA MD ME Office) $ $ 1 2 If yes, explain Previous Year Established Year Own or (O or L) Lease MI MN MO MS MT NC ND $ $ Number, Street Lease Payments Current Year 1 2 Maximum No.
SECTION 4 - Filing Information
SECTION 5 - Vehicle Information
of Vehicles Stored If yes, explain Location Address Inside Value of all City, State, Zip Code
Maximum Vehicles $ $
If yes, complete the following:
NE NH NJ NM NV NY OH Upcoming Year 1 2
check Box 2 for each state entered.
Maximum Vehicles No. of Outside Relationship to Named Insured
Do you provide the
Value of all Public Liability Maximum Vehicles Insurance? OR OK PA RI SC SD TN 1 2 (Y or N) Fenced Description of Operations (a) (b) 65. 66. 67. 68. 69. (b) (c) 70. 71. 72. Is Lot
Do you provide the Compensation? Lighted (Y or N) Workers' Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes ARF2275D TX UT VA VT WA WI WV WY Security (Y or N) Guard 1 2 No No No No No No No No No No No No No
74. Number of Vehicles Operated in the Business (show all equipment even if you do not intend to insure): 75. 76. 77. 78. 79. 80. 81.
*1. Seating Capacity - Include total front passenger capacity (excluding driver) and rear seating capacity.
*2. Position of rear seats, list all that apply: (a) facing forward (b) facing rear (c) left side (d) right side (e) jump seats *3. Designate vehicle type:
82. PREMIUMS (To Be Completed by Agent)
TOTAL
Sedan Formal Stretch to 60"
Super Stretch (over 60") Van Stretch Van Mini Bus Motor Coach Others Unit Unit
TOTAL PREMIUM ALL COVERAGES $
Unit # 1 2 3 4 5 # 1 2 3 4 5 # 1 2 3 4 5
Can any vehicle provide open air seating such as rumble seat, hot tub, convertible? Is any vehicle equipped with bulletproof glass or armor plate?
Is any vehicle equipped with duel rear wheels? Do you service your own vehicles?
How many mechanics do you employ? (a)
(b)
VEHICLE SCHEDULE - Complete all information for each unit (if more space needed use additional applications)
Mileage Radius Model
Do you have a parts department? Do you service vehicles of others?
Year Liability Estimated Mileage Make/Model Annual Base Car Equipment (A) Armored (B) Open Air (C) Dual Rear P.I.P.
S - Sedan F - Formal ST - Stretch SS - Super Stretch V - Van SV - Stretch Van MB - Mini Bus MC - Motor Coach Other
Serial # (VIN)
(D) Anti-Lock (E) Air Bags (F) Anti-Theft Vehicle Devices Breaks Added P.I.P. If no, explain Purchased Date Width of Stretch (Inches)
Number of Owned Vehicles
Auto Medical
If yes, list unit #
Payments Length of Cost New (Inches) Stretch
Are they certified?
Capacity Seating *(1)
Purchase
PHOTOGRAPH REQUIRED FOR EACH VEHICLE WITH A VALUE OF $50,000 OR MORE.
Uninsured Motorists Price
If yes, list unit #
Leased Without Drivers
Position of Rear Seats
*(2)
Number of Long Term Leased Vehicles
Current Value Underinsured Motorists Coach Builder Limousine Or Hired (H) Owned (O) Leased (L)
If yes, list unit #
Owner Operators Business Coach Builder U.M. P.D. Still in Y/N Purpose of Use Vehicle Type *(3) Causes Of Loss Specified 80. Liability 75. 76. 77. 78. 79. (a) (b) Total Vehicles Coverage Desired (Y) Yes - (N) No Specified Causes of Garaging Location Loss Yes Yes Yes Yes Yes Yes Yes ARF2275E Collision Collision No No No No No No No
the policy effective date and in accordance with all policy terms. The Applicant acknowledges that the
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.
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.
ment to be attached to the policy which increases Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that endorsement.
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.
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.
has personally signed below (or if Applicant is a Corporation a corporate officer has signed below).
Will premium be financed?
Witness
83. (a) Provide loss experience from prior insurance carriers for past full three years.
/ / / / / / / / From (b)
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 Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely
If any jurisdiction in which the Applicant intends to operate or the Interstate Commerce Commission requires a special
endorse-The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and
The Applicant represents that she/he has completed all relevant sections of this Application prior to excution and that the Applicant
Is this direct business to your office? Is this new business to your office? How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Policy Term
Is any insured 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? If yes, provide complete details
Please quote
Please bind at earliest possible date and issue policy Please issue policy effecitve
List in order with most recent carrier first.
/ / / / / / / /
To
Applicant's Representative's Name and Address
Insurance Company Name
Yes
(Time andDate Bound by General Agent)
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE MUST BE SIGNED BY THE APPLICANT PERSONALLY
SECTION 6 - Prior Loss Experience
No
Policy No.
Applicant's Signature
If yes, with whom
If not, explain:
If not, how long have you had the account?
No. of Power
Units Accidents
Coverage was bound by
No. of
Liab
(Name of Person in Company General Agent's Office Binging Coverage)
Premium
Phys Dam BI
Total Amount Claims Paid & Reserve
Applicant's Representative Phone No. PD (b) Yes Coll Date ARF2275F Other No
