Commercial Automobile Insurance Application

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1 COMMERCIAL AUTOMOBILE INSURANCE APPLICATION Application Requirements: 1. FULLY COMPLETED APPLICATIONS: 1. Our Supplemental; 2. Acord 125; and 3. Acord 127. If additional space is needed, please use your firm's letterhead. Application must be Dated and Signed by Insured. 2. LOSS RUNS: We require five years of recently valued loss runs. General Applicant Information 86 Carleton Avenue P.O. Box 599 East Islip, New York (631) Voice (631) Fax Name of Applicant: FEIN#: US DOT#: Applicant s Practice 1. Describe how the following types of vehicles are used in your business? Type of Vehicle Private Passenger Passenger vans Light Trucks/Cargo Vans Medium Trucks Heavy/X-Heavy Trucks Tractors/Trailers Est. Annual Mileage per vehicle Are any of the trucks used for snow plowing roads or parking lots? If yes, provide details: 2. Approximately what percentage of time do your commercial vehicles travel? Within 50 miles % Between miles % Over 200 miles % 3. How many power units (exclude trailers) were in your fleet in the past? # of autos one year ago # of autos two years ago # of autos three year ago # of autos four years ago 4. Identify which of the following driver hiring criteria you have in place? Brownyard Programs, Ltd. 1 of 6

2 a. MVRs checked prior to hire? At least annually thereafter? b. Physical exams at time of hire? c. Drug/Alcohol testing at time of hire? d. Reference check? e. Require CDL when applicable? f. Road test given prior to hire? g. Orientation in vehicle with experienced driver? If yes, for what period of time? h. Number of drivers under age 25 Total # of company drivers Total # of employees # of company drivers employed less than one year i. Minimum # of years of driving experience required on like equipment? j. How long have all of these procedures been in place Describe your standards for an acceptable MVR below or attach copy of criteria: Is your MVR criteria above in writing and always followed? If exceptions are ever made, please describe: Any other actions taken in regard to driver hiring, selection or training? 5. Is there a formal accident review program in place? How long has the program been in place? 6. Is there a progressive discipline policy for drivers involved in serious of multiple accidents/violations, etc,? If yes, how long has the program been in place? Brownyard Programs, Ltd. 2 of 6

3 7. Do you provide safety incentive awards? If yes, how long has the program been in place? 8. Do you have a company policy regarding non-business use (personal use) of your company autos by employees or executives? How long has the program been in place? How often/when is it communicated to your employees? Is this policy in writing? If yes, please forward a copy. 9. As part of your personal use policy, do you allow employees or executives to use company insured vehicles for non-business (personal) use? If no, skip to question 10. If yes: Is personal use restricted to certain employee types (e.g., management only)? If yes, describe: Do you allow the authorized users spouse to use the company vehicle? Do you allow the authorized users children to use the company vehicles? Are there any family members under age 21 given permissive use? On a separate page, please provide the name, date of birth and driver license number of any spouse or children of employees who are permitted to drive a company vehicle. 10. Do any of your employees use their own vehicles in the course of employment, twice a week or more? If no, skip to question 11. If yes: How many employees do this on a regular basis? Do you check their MVRs and use the MVR criteria mentioned above? Do you require certificates of insurance to make sure employees are carrying personal auto coverage including bodily injury liability coverage? If yes, how often do you request certificates? Do you require the employee to carry a minimum limit of liability? Brownyard Programs, Ltd. 3 of 6

4 If yes, what minimum limit is required? Do you make sure any business use exclusion on their policy is deleted? 11. Do you rent or lease vehicles for your use on a short term basis (daily/weekly/monthly)? If yes, please describe this exposure and the length of the rentals/leases: How many time per year is this done? What types of vehicles do you rent or lease? Do you ever rent or lease vehicles with drivers? If yes, how often and what are the vehicles used for? Estimated annual cost of hire? 12. Do you lease drivers from others? If yes, how many driver your company owned (or long term leased) vehicles? Does your MVR criteria apply to these drivers? Other controls you exercise over these drivers? 13. Do you use owner operators to haul on your behalf? 14. Are your vehicles on a preventive maintenance program? Are pre/post trip inspections conducted on the heavy units? Are any vehicles equipped with GPS or similar systems? Are any vehicles equipped with speed governors? If yes, what is the maximum speed? 15. Do you have any restrictions on the use of cell phones while operating company vehicles (hands free device only, must pull off side of road, etc.)? Thank you for your cooperation in completing this supplement to assist us in underwriting your account. Brownyard Programs, Ltd. 4 of 6

5 Notice and Representations The Company and the Insured Persons declare that the statements set forth herein are true. The signing of this application does not bind the Underwriter, the Policyholder or its Insured Persons to effect insurance. The undersigned agrees that this application, its attachments and any materials submitted therewith are true, complete and accurate as of the date thereof. These representations shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. The application, its attachments and any materials submitted therewith are considered physically attached to the policy and will be deemed incorporated by reference therein. The Underwriter is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. The undersigned, on behalf of the Company and all Insured Persons, agrees that if the information in the Declarations and representations contained in this application and its attachments materially changes between the date of this application and the inception of the proposed coverage, the undersigned will immediately report in writing to the Underwriter such change, and the Underwriter may withdraw or modify any outstanding quotations or agreements to bind coverage. The undersigned acknowledges and agrees that the Underwriter's receipt of such written report, prior to inception of the proposed coverage, is a condition precedent to coverage. FRAUD WARNINGS GENERAL STATEMENT: 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 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, MD, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied). 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE 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 and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. APPLICABLE 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. APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Brownyard Programs, Ltd. 5 of 6

6 APPLICABLE IN MARYLAND: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. APPLICABLE 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. APPLICABLE IN OHIO: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty or insurance fraud. APPLICABLE IN OKLAHOMA - WARNING: Any person who knowingly, and with intent to injury, 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. APPLICABLE 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. MUST BE SIGNED BY THE PRESIDENT, CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER OR IN-HOUSE GENERAL COUNSEL OF THE POLICYHOLDER ON BEHALF OF ALL INSUREDS. Signature of Owner, Partner or Principal of Applicant Title Date Signature of Applicants Agent or Broker Title Date Brownyard Programs, Ltd. 6 of 6

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