BUSINESS AUTO FLEET SUPPLEMENTAL APPLICATION
GENERAL INFORMATION
Date:
Applicant Name:
RISK PROFILE
1. Years in business:
2.
Does the applicant engage in interstate commercial trade?
☐
Yes
☐
No
3. Does the applicant have any outstanding ICC or PUC Filings:
☐
Yes
☐
No
If yes, please check all that apply:
☐
BMC-91
☐
BMC-91X
☐
FORM E (Various)
☐
MCP-65 (CA),
☐
TL672 (CA),
☐
MC1641 (CT)
☐
OS32 (OH)
☐
Oversized/Overweight COI (AL, AR, LA, MS, or PA)
4.
DOT #:
MC #:
Year
(Excluding PPT’s and Trailers)
Total Unit Count
Mileage per Unit
Average Annual
Current
1st Prior
2nd Prior
3rd Prior
4th Prior
5. Radius of Operations
0 – 50 Miles %
51 – 200
%
Over 200
%
6. Operating Area(s)
Urban %
Suburban
%
Rural %
7. Delivery operations?
☐
Yes
☐
No
HCC AUTO (08/15)
Page 2 of 5
8. Do you perform any backhauling or hauling goods for others?
☐
Yes
☐
No
a. If yes, please explain:
b. Please indicate percent of driving:
%
9. Do you use owner-operators for any of your driving?
☐
Yes
☐
No
If yes,
a. How many are owner-operators do you have?
b. Are the owner-operator vehicles included in this submission?
☐
Yes
☐
No
c. Are permanent/exclusive lease agreements used?
☐
Yes
☐
No
d. Are drivers subject to the same hiring and training requirements as employees?
☐
Yes
☐
No
e. Are their vehicles subject to the same maintenance and inspection requirements as
your owned vehicles?
☐
Yes
☐
No
10. Number of drivers:
Full Time
Part-time
Volunteers
11. Please provide the annual driver turnover using the following formula:
Current:
1
stPrior:
DRIVER MANAGEMENT
Does the applicant:
1. Perform pre-employment screening?
☐
Yes
☐
No
If yes, does the selection process call for:
☐
Written application
☐
Physical Exam
☐
Reference Check
☐
Substance Abuse Test
☐
Written Test
☐
Road Test
☐
Motor Vehicle Record Check
☐
Provisional Hiring Period
2. Have a written driver training program?
☐
Yes
☐
No
3. Have a ride-a-long program?
☐
Yes
☐
No
If yes, how long?
4. Do drivers operate the same unit every day?
☐
Yes
☐
No
5. Have any employees that regularly drive their own cars on company business?
☐
Yes
☐
No
If yes, what percent of total driving is done in non-owned vehicles? %
(Annual no. of driver terminations + Annual no. of driver resignations)
(Driver employed at year's start + Drivers emplyed at year's end/2)
SAFETY MANAGEMENT
Does the applicant:
1. Have a written and enforced fleet safety program?
☐
Yes
☐
No
2. On what basis are fleet safety meetings held?
☐
Weekly
☐
Monthly
☐
Quarterly
Is attendance at the fleet safety meetings taken and recorded?
☐
Yes
☐
No
3. Have a written and enforced vehicle personal use / take-home policy?
☐
Yes
☐
No
4. Have a family-use policy?
☐
Yes
☐
No
5. Have a distracted driving policy?
☐
Yes
☐
No
6. Employ a full-time Risk Manager?
☐
Yes
☐
No
7. Have a formal accident investigation / review procedure in place?
☐
Yes
☐
No
If yes, please describe:
8. Have a progressive discipline policy for drivers involved in multiple accident/violations?
☐
Yes
☐
No
9. Have safety incentives for drivers?
☐
Yes
☐
No
If yes, please describe:
VEHICLE PROFILE
1. Does the applicant engage in interstate commercial trade?
☐
Yes
☐
No
2. Are vehicles equipped with the following?
☐
Backup Alarms
☐
Two-way Radios
☐
Reflective Tape / Paint
☐
DriveCam Technology
☐
Blackbox
☐
GPS Technology
If vehicles are equipped with GPS technology does the applicant use GPS reports to
monitor safety?
☐
Yes
☐
No
If yes, please describe:
3. Have a written vehicle maintenance program in place?
☐
Yes
☐
No
4. Is there a daily documented inspection of vehicles?
☐
Yes
☐
No
HCC AUTO (08/15)
Page 4 of 5
5. Does the applicant maintain proof that inspections and repairs have been performed by
FMCSA qualified mechanics (See 49 CFR 396.19 and 49 CFR 396.25)?
☐
Yes
☐
No
SUBMISSION REQUIREMENTS
☐
ACORD 125
☐
ACORD 127
☐
DRIVERS LIST
☐
Copy of fleet safety plan (if applicable)
☐
Five years currently-valued loss runs
ADDITIONAL NOTES:
FRAUD NOTICE STATEMENTS
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. 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. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCE IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOU STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (NOT APPLICABLE IN AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, OR WV.)
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 and subjects that person to criminal and civil penalties. (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA and WV).
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.
Applicable in Florida and Oklahoma: 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 (In FL, a person is guilty of a felony of the third degree).
Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in Maine, Tennessee, Virginia and 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 may include imprisonment, fines or a denial of insurance benefits.
