PUBLIC TRANSPORTATION FLEET CHECKLIST

Transcription

1 ONE INTERNATIONAL BLVD. SUITE 405 MAHWAH, NJ Phne (201) Fax (201) PUBLIC TRANSPORTATION FLEET CHECKLIST Applicant Name: Prpsed Effective Date: Agency: Requested Qute Date: Prducer: Address: Phne: Fax: Are yu the incumbent agent? Yes N The fllwing supplemental infrmatin is required t prperly underwrite the applicant and must be attached with this applicatin: Financial Statements: Balance sheets and incme statements fr the past tw year end perids and the mst recent interim r quarterly statement if the year-end statement is mre than six mnths ld. If the business is nt incrprated the mst recent Federal tax return shuld be prvided instead. Parent cmpany financials, if applicable, shuld be prvided. Lss Runs: Insurance cmpany-prduced lss runs with claim detail fr the current and mst recent three years. Lss runs are t be valued within the past 90 days. Equipment Schedule: Current listing f all vehicles. Include year, make, mdel and current stated value. If the vehicle is a stretched limusine prvide the length f stretch. Drivers List: List f all drivers including name, license number, date f birth and date f hire. Mileage: If the applicant perates interstate prvide fuel tax reprts fr the mst recent eight quarters. MVR s: Required. Page - 1 -

2 NAMED INSURED INFORMATION PUBLIC TRANSPORTATION INSURANCE APPLICATION 1. NAMED INSURED: 2. MAILING ADDRESS: 3. PRINCIPAL GARAGING ADDRESS: (As it appears n all regulatry filings) Street address City Cunty State Zip Street address City Cunty State Zip 4. Phne# Fax# 5. Safety Survey Cntact Name: Phne# 6. Named Insured is: Crpratin Partnership Sle Prprietr Federal Emplyer I.D. #: 7. Name f all entities t be insured, year established and descriptin f each: Entity Year Business Established Descriptin f Operatins 8. Prvide the fllwing infrmatin fr all fficers, directrs, partners and stckhlders f the Named Insured: Name Psitin / Functin Full-time / Part-time N. f years Years f Transit Experience Pct. Ownership 9. Prvide the name(s) f any public transprtatin entity(ies) nt cvered under this applicatin in which the Named Insured r any f its fficers, directrs, partners r stckhlders have a direct r indirect wnership interest; OPERATIONS INFORMATION Please describe in detail yur peratins (attach additinal peratinal descriptins as necessary): 1. Have yu ever lst r had any authrity withdrawn by any regulatry authrity (Interstate Cmmerce Cmmissin, Public Utilities Cmmissin, etc.) r are yu under current prbatin? Yes N If yes, explain in detail here r n a separate sheet. 2. D yur vehicles ever transprt any cmmdities, ther than passenger baggage r mail? Yes N If yes, describe types f cmmdities and include cpies f bills f lading issued r cpies f cntracts. 3. D yur vehicles ever transprt prfessinal athletic r entertainment grups? Yes N If yes, please explain 4. List belw yur average number f revenue-prducing units, mileage and grss receipts fr the prpsed, current and three previus plicy perids. Page - 2 -

3 Year Revenue Units Mileage Grss Receipts 12 Mnths Prjected: Current Plicy Year: 1st Prir Plicy Year: 2 nd Prir Plicy Year: 3 rd Prir Plicy Year: 5. Fr each f the fllwing categries, indicate yur prjected (A) receipts fr the prpsed plicy perid, (B) ttal mileage fr the prpsed plicy perid and (C) number f units (ttals shuld match the data in #4.A.). Vehicle Categry: Buses Vans Pvt Pass Service Schl Airprt Sightseeing Regular rute intercity Charter Urban Transit Limusines Wheelchair-Accessible vehicles Other (describe) (If mre than 10% f fleet, cmplete Supplemental Wheelchair Applicatin) 6. Charter and Tur Operatrs: List yur ten mst frequent destinatins: City r Attractin ST % f Trips City r Attractin ST % f Trips List the destinatins f the five lngest trips made in the past 12 mnths: 7. Schl Cntractrs: List the schls r schl districts and their lcatins with which yu have cntracts: 8. Indicate % f disabled / handicapped ridership: 9. Demand Respnse Transit: Please indicate % f ttal trips: On call vs Scheduled Dr t Dr vs Curb t Curb 10 D yu utilize wner-peratrs in yur business? Yes N a. If yes, please list the number f wner-peratrs: ; and prvide a cpy f wner-peratr agreement. b. Will they be included under this insurance? Yes N c. Is persnal use f vehicles permitted? Yes N If yes, are wner-peratrs required t prvide prf f insurance fr persnal use f their vehicle? Yes N D yu ever lease vehicles with drivers t thers? Yes N Please explain: D yu ever lease vehicles withut drivers t thers? Yes N Page - 3 -

4 PRIOR LOSS EXPERIENCE AND COVERAGE INFORMATION 1. Attach currently valued lss runs frm yur insurance carriers fr each f the past five (5) plicy perids. Please prvide details n any lss ccurrences that exceed $100,000 r invlve a fatality r serius injury n a separate sheet. 2. Prvide the fllwing infrmatin fr the current and past five (5) plicy perids: Current Plicy Perid Prir Fur Plicy Perids Insurance carrier Plicy effective date Liability limits Deductible r SIR Annual premium 1. Aut Liability 2. Physical Damage Ttal Lsses 1. Aut Liability 2. Physical Damage 3. Valuatin Date 3. Has yur insurance ever been btained thrugh an Assigned Risk Plan? Yes N If Yes, please explain: 4. Has any cmpany, during the past three years, cancelled r refused t renew yur autmbile insurance cverage? Yes N If yes, please explain: SAFETY INFORMATION 1. Please prvide name, title, and years f experience f persn(s) respnsible fr safety: Other duties: 2. D yur Driver selectin prcedures include: A. Written applicatins? Yes N B. Reference checks? Yes N C. Written test? Yes N D. Rad test? Yes N E. Physical exam? Yes N (1) Pre-emplyment? Yes N (2) Federal DOT requirements? Yes N (3) State DOT requirements? Yes N F. D yu btain driver MVR recrds? Yes N G. D yu MVR recrds peridically during emplyment? Yes N Pre-emplyment Pst-emplyment H. Drug testing prir t hiring? Yes N During emplyment? Yes N 3. Des driver indctrinatin include: A. Cmpany rules and plicies? Yes N B.Daily DOT vehicle inspectin prcedures? Yes N C. Equipment familiarizatin? Yes N D Rute familiarizatin? Yes N E. Emergency prcedures? Yes N F. Accident reprting prcedures? Yes N 4. Des rad supervisin include: A. Mechanical recrding devices? Yes N B. Radi dispatch? Yes N Are accident investigatin and review prcedures, including recrds, maintained? Yes N D the review prcedures 5. include disciplinary prcedures? Yes N If yes, explain: 6. Attach cpies f latest DOT r applicable state authrity inspectin reprts, if such inspectins are made. DRIVER INFORMATION 1. Attach schedule f drivers including date f birth, date f hire, and number f years f experience. 2. Current ttal number f drivers: 3. During the last 12 mnths, hw many drivers have yu: Replaced? Added? Page - 4 -

5 4. Driver s pay is calculated by trip mileage hurly ther (explain): 5. Drivers are: Unin Nn-Unin 6. Driver s maximum hurs: a Driving daily, weekly b On duty daily, weekly 7. D yu ever lease vehicles with drivers: a.) frm thers? b.)t thers? MAINTENANCE INFORMATION 1. D yu have a written maintenance prgram? If yes, please attach a cpy. 2. D yu service yur wn vehicles? Yes N If n, wh des? 3. Hw many mechanics d yu emply? 4. D yu service vehicles f thers? Yes N 5. If yu service vehicles f thers what is the annual grss revenue? $ 6. Des vehicle maintenance prgram include: A service recrd f each vehicle (attach cpy)? Yes N N/A Cntrlled inspectin frequency? Yes N N/A Vehicle daily cnditin reprts (attach cpy)? Yes N N/A The abve fr leased vehicles? Yes N N/A Hw ften are these varius reprts reviewed by management? EQUIPMENT INFORMATION 1. Attach cmplete schedule f equipment including year, make, mdel and current stated amunts if Physical Damage cverage desired. 2. If the applicant s fleet includes limusines are any f the vehicles stretched? Yes N N/A If yes, specify the length f the stretch fr each applicable vehicle n the vehicle list. 3. Was the vehicle(s) specified in questin 2 mdified by a Qualified Vehicle Mdifier (QVM)? Yes N N/A If yes, specify the name f the mdifying firm(s): 4. D yu wn r perate any equipment nt listed n the schedule? Yes N If yes, explain: 5. Schedule f all lcatins: (Attach separate sheet if necessary.) Address Type f peratin (ffice, terminal, garage, etc.) # Units stred inside & maximum values # Units stred utside & maximum values Is lt fenced? Watchman r security? Owned r Leased? Lcatin 1 Lcatin 2 Lcatin 3 6. Please explain cmpletely if any equipment is nt garaged r stred at abve lcatins: 7. Private passenger vehicles use please state in percentages: A. Use f vehicles: business nly business & pleasure B. Operated by: emplyee nly family spuse ther GENERAL LIABILITY & GARAGE LIABILITY COVERAGE QUESTIONS (leave blank if cverages nt required) Office Area Garage area Parking Area Vacant Land (acres) Lcatin 1 Lcatin 2 Lcatin 3 1. Please describe any ther General Liability expsures: 2. Cntractual include cpies f cntracts 3. Please describe any General Liability lsses fr current and past three years and prvide currently-valued lss runs. 4. A. Hw many times during the past 12 mnths have yu serviced r repaired equipment f ther peratrs? B. Estimated annual revenue frm this wrk $ Page - 5 -

6 C. Types f wrk perfrmed: D. Types f vehicles serviced?: 5. Please describe any Garage Liability r Garagekeepers lsses (separately) fr current and past three years and prvide currently-valued lss runs. DESIRED COVERAGES Requested Cverages Cmmercial Aut Liability Hired Aut Liability Nn-Owned Aut Liability Uninsured Mtrists Underinsured Mtrists Supplemental Uninsured Mtrists (NY) Optinal Basic Reparatins Benefits (CT) Medical Payments Persnal Injury Prtectin Prperty Prtectin Ins. (MI) Cmmercial General Liability Specified Perils Cmprehensive Cllisin Garage Liability Garagekeepers Legal: (list ther lcatins n separate sheet) Cmprehensive Cllisin Other Limit and Deductibles Limits Deductible Additinal ptins, cmments: FILINGS INFORMATION 1. If Interstate Cmmerce Cmmissin filing is required, prvide I.C.C. Dcket N.: MC 2. List States r ther regulatry agencies that require filings (prvide Dcket # s fr CA, IN, KY, NM, TX): 3. List states where the applicant has vehicles licensed and/r garaged and where filings are required. (Check under clumn F fr states in which yu require liability filings and under clumn V fr states in which vehicles are licensed / garaged): F V F V F V F V F V Canada Filings AL GA MA NM SD F V AK ID MI NY TN Alberta AZ IL MN NC TX British Clumbia AR IN MS ND UT Manitba CA IA MO OH VT New Brunswick CO KS MT OK VA Newfundland CT KY NE OR WA Nrthwest Territry DE LA NV PA WV Nva Sctia DC ME NJ RI WI Ontari FL MD NH SC WY Prince Edward Island 4. Please specify yur hme state fr Single State Registratin: Page - 6 -

7 COVERAGE NOT AVAILABLE FOR MEXICAN OPERATIONS. PRODUCER INFORMATION Prducer: Address: City: State: Zip: The Cmpletin f this applicatin creates n express r implied bligatin n the part f W.F. Claytn & Assciates, LLC t ffer r prvide insurance as requested in this applicatin and survey. General Fraud Statement (Nt applicable in Clrad, Nebraska, Ohi, Oklahma, Oregn, Utah and Vermnt) Any persn wh knwingly and with intent t defraud any insurance cmpany r anther persn files an applicatin fr insurance cntaining any materially false infrmatin, r cnceals fr the purpse f misleading infrmatin cncerning any fact material theret, cmmits a fraudulent insurance act, which is a crime and subjects the persn t criminal and civil penalties. In the District f Clumbia, Luisiana, Maine, Tennessee and Virginia, insurance benefits may als be denied Prducer s Signature Senir Officer f Applicant Title Title Date Date Page - 7 -