2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 1 of 9
Towing V₃antage
®Towing and Recovery Application
Email to: towing.brokerservices@v3ins.com
GENERAL INFORMATION
Proposed Policy Period: To
Insured Name: DBA (if any): Location 1 Address:
City: State: Zip:
Location 2 Address:
City: State: Zip:
Mailing Address:
City: State: Zip:
Legal Entity: Corporation Partnership LLC Individual / Sole Proprietor FEIN or SSN:
Website Address: Email Address:
Businesss Phone:
Other Related Entities (name, date started, describe operations):
List all Owners Title Year Bus Started % Ownership Active? Years Managing
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 2 of 9 Coverage Requested
A. Business Auto
Type Symbols Limit-CSL
Business Auto Liability 7,8,9 Uninsured Motorist 7 Medical Payments 7
PIP/No-Fault 7
Type If Any
Non-Owned Liability Cost of Hire Hired Liability
Type Symbol Ded
Business Auto Physical Damage 7 Comp/OTC
7 Collision
Garagekeepers Legal Liability Direct Primary
(n/a all states) Direct Excess
Location Limit of Liability Deductible Deductible
Comprehensive Collision
1
2
3
4
B. General Liability (Occurrence Only)
Type Limit
General Aggregate $
Each Occurrence $
Damage to Rented Premises $
Medical Expense $
Driver Payroll: $ All other Towing payroll (including clerical, admin, officers and owners): $ Lot Size and Protection
Loc Sq Feet of Loc Alarm Fully Fenced Camera Well Lit Sec Guard 24 hr Staff Animals
1
2
3
4
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 3 of 9 Sales/Revenues Both columns for percentage and annual dollar sales must be completed
Desc Sales Annual Sales Pct Desc Sales Pct Annual Sales
Towing Tire Sales – New*
Roadside Assistance Tire Sales – Used*
Parking/Storage Tire Sales – Recapped*
Involuntary Repo Auto Sales (not lien)
Voluntary Repo Service/Repairs- need ASR App Parts Sales –Used/Salvage Body/Paint –need ASR App
Parts Sales - New Rental/Leasing Operations
Trucking/Freight Hauling Other – describe fully
Mobile Home Transport TOTAL SALES 100%
* Are any tires sold by you manufactured in China? Yes No Towing
1. How many tows each month?
2. How many roadside assistance calls each month?
3. Show percentage of all types of your towing operations:
Private Property (illegal parking) City/County/State Towing Highway/Turnpike Rotation
Voluntary Repossesions Involuntary Repossesions Heavy Duty Commercial Tows
Banks/Finance Companies Motor Club Towing Towing for your own business
4. Are your tow trucks equipped with scanners? 5. Do you do any “chase” or “first on scene” towing?
6. Are all tows required to be dispatched by your office dispatcher?
Exposure History:
Current 1st Prior Yr 2nd Prior Yr 3rd Prior Yr 4th Prior Yr 5th Prior Yr Vehicles
Employees
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 4 of 9 Employee List
IMPORTANT –Show all employees including those who drive company cars (including family members who use car) and employees who drive their personal vehicle on company business including ANYONE furnished a vehicle whether they are employed by insured or not. Use the Driver Supplemental Form for additional employees/drivers.
Name Date of Birth Date of Hire Job Duties / Title CDL? Status
1 Yes Full Time
No Part Time
2 Yes Full Time
No Part Time
3 Yes Full Time
No Part Time
4 Yes Full Time
No Part Time
5 Yes Full Time
No Part Time
6 Yes Full Time
No Part Time
7 Yes Full Time
No Part Time
8 Yes Full Time
No Part Time
9 Yes Full Time
No Part Time
10 Yes Full Time
No Part Time
11 Yes Full Time
No Part Time
12 Yes Full Time
No Part Time
13 Yes Full Time
No Part Time
Copies of MVR’s required for each person who (1) drives a company owned vehicle, or (2) regularly drives their own personal vehicle on company business. A Non-Owned Supplemental Application must be completed for all employees who use their vehicle regularly on company business.
Are all drivers covered by workers compensation
insurance? Yes No If yes, name
of carrier: Are any owners or employees furnished an auto?
If furnished, provide name and vehicle: _________________________________
Yes No
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 5 of 9 Vehicle Schedule Mandatory for NY: Provide License Tag numbers
Veh No Model Year Vehicle Make Body Type GVW Nbr Loc Value* VIN On-Hook Limit On-Hook Ded
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
*Values provided are Original Cost New ACV or Stated Value
Radius of Operations: Percent (0-50 miles) % 51-200 miles? % over 200 miles? %
Regulatory Filings
7. Do you require a Federal filing? 8. Do you require a State Filing?
9. Do you require a MCS-90 endorsement?
10. Do you ever perform secondary tows of hazardous materials? 11. Do you ever tow/move hazardous materials on a primary haul basis? 12. MC/DOT Number?
13. State Docket Number?
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 6 of 9 Safety Management
14. Describe your safety program:
15. How often do you hold safety meetings? 16. Describe your driver training program:
17. Describe your vehicle take home policy/procedures: 18. Describe your drug testing policy/procedures: 19. Describe your accident review procedures:
20. Name and title of person in charge of Safety program? Maintenance
21. Do you maintain maintenance logs on all vehicles? 22. How often is routine maintenance performed? 23. Do you perform the routine maintenance?
24. Is maintenance provided by professional certified mechanics? 25. Do your drivers perform daily maintenance checks on all vehicles?
26. Are your drivers responsible for any cost of the maintenance of the vehicles? 27. Are your vehicles subject to an annual state inspection?
Driver Management
28. Do you obtain a MVR (Motor Vehicle Record) on all drivers before hiring? 29. How often do you obtain an MVR on your drivers?
30. Do you maintain driver files on all drivers including MVR’s and copies of tickets? 31. Do all your drivers meet all local, state and federal license requirements? 32. Do you require job references?
33. Do you check job references?
34. Do you road test all drivers prior to hiring?
35. Desribe your disciplinary/termination procedures:
36. Do you issue a 1099 to any employees or independent contractors? 37. Describe how drivers are compensated:
38. How many drivers quit or were fired last year? 39. How many drivers were hired last year?
40. How many drivers do you expect to hire this year?
41. Are your drivers required to take internal or external training courses?
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 7 of 9 Repossesions
42. Who issues the assignment to pick up a car?
43. Are the debtors notified in advance and agree to the repossession? 44. What is your policy if the debtor changes their mind?
45. Do you perform involuntary repossessions? Truck / Freight Hauling
46. Do you have any contracts to haul cargo for specific clients? 47. Do all drivers have CDL Class “A” licenses?
48. What cargo or commodities do you haul?
49. Do you haul, transport, tow or set up mobile/modular housing? 50. What is the maximum distance traveled?
51. What is your average distance? Operations
52. Do you lease vehicles from other companies or individuals? 53. Do you lease vehicles to other companies or individuals? 54. Do you hire sub-contractors at any time?
55. Do you own or lease any cranes or forklifts?
56. Do you have any vehicles owned or leased by you that are NOT on this schedule? 57. Do you require the use of safety chains on every tow?
58. Do you require the use of wheel lift straps on every tow? 59. Do you require the use of vehicle towing lights on every tow? 60. How many lien sales per month?
61. Do you dismantle autos or have salvage/recycling operations?
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 8 of 9 1. Will lessor be added as add’l insured? Yes No If yes, give name and address of lessor in narrative. 2. Will loss payee be added? Yes No If yes, give name and address of loss payee in narrative.
Prior Insurance and Loss History Information (3 years)
Policy Period Carrier Premium
Loss Runs Required. Provide minimum of current plus two prior years loss history for all coverage requested.
Has similar insurance ever been cancelled, declined or not renewed? (Not applicable in Missouri) If “yes”, explain:
Narrative / Other Coverage Wanted
2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 9 of 9 Disclosures and Notices
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
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. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied) IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. IN THE DISTRICT OF COLUMBIA, WARNING: 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, FINES, AND DENIAL OF INSURANCE BENEFITS
THE POLICY OF INSURANCE APPLIED FOR DOES NOT PROVIDE COVERAGE AS REQUIRED BY ENVIRONMENTAL PROTECTION AGENCY (EPA) 40 CFR PARTS 280 AND 281 FOR UNDERGROUND STORAGE TANKS. NO COVERAGE UNDER CERLA OR SIMILAR STATE OR FEDERAL ENVIRONMENTAL ACT(S). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION.
SIGNATURE OF APPLICANT
I have read this supplement and certify that the answers and information herein are true and correct to the best of my knowledge.
Signature of Insured:
Print Name:
Date:
The undersigned is an authorized representative of the applicant and represents that reasonable enquiry has been made to obtain the answers to questions on this application. He/she represents that the answers are true, correct and complete to the best of his/her knowledge.
SIGNATURE OF PRODUCER
Signature of Producer:
Print Name of Producer:
Name of Agency:
Date:
Need State Producers license Nbr (required in FL):
