CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE INSURANCE

Transcription

1 370 West Park Avenue, P. O. Box 9004, Long Beach, NY Tel: (516) Fax:(516) CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE INSURANCE Important Instructions 1. All information requested in this application should be typewritten or printed in ink. 2. All questions must be answered completely. 3. This application cannot be processed unless signed by the Named Insured. 4. This application cannot be processed unless the following documents are provided: A Complete Equipment Schedule include a copy of each vehicle s regstration. Completed Drivers Information Schedule Current motor vehicle record for each driver (For current transportation operators) - Currently valued insurance company loss runs for the past three (3) years or a signed claims statement 5. Additionally, please attach copies of the following written forms and procedures used by the Named Insured: Driver Criteria Maintenance Program Safety Program 6. The effective date of the coverages requested under this application is. 7. A quotation for the coverages requested under this application is needed no later than. THE COMPLETION OF THIS APPLICATION CREATES NO EXPRESS OR IMPLIED OBLIGATION ON THE PART OF LANCER INSURANCE COMPANY OR ITS MANAGER TO OFFER A QUOTA- TION OR PROVIDE INSURANCE AS REQUESTED IN THIS APPLICATION AND SURVEY. This Application and Survey for Public Automobile Liability and Physical Damage Insurance is copyrighted and material appearing within may not be reproduced in any form without the written permission of Lancer Insurance Company Lancer Insurance Company

2 Please provide us the following general information. 1. NAMED INSURED: 2. MAILING ADDRESS: CITY COUNTY STATE ZIP 3. BUSINESS ADDRESS: CITY COUNTY STATE ZIP 4. Named Insured is: Corporation Partnership Sole Proprietor Other 5. Name of all entities to be insured, year established and detailed description of operations of each Year Description Entity Established of Operations 6. Provide the following information for all officers, directors, partners and stockholders of the Named Insured: Position/ Full Time/ No. of Years of Percentage Name Function Part Time Years Experience Ownership 7. Name and telephone number of person to be contacted for safety and accident prevention services: Name: Telephone No.: ( ) Please tell us about your operation. 1. Are you required to file evidence of Automobile Liability Insurance with any Federal, State, County, Municipal, Town, Employer or other authority? Yes No 2. If Yes, please complete the following: State requiring such evidence: Name and address of entity(ies): What form of evidence is required? 3. Is this a start-up operation? Yes No 4. Please provide the following information for your current policy period requested under this application (If the answer to #3 is yes, just provide proposed policy period data): Proposed Current Prior Four Policy Period Policy Period Policy Periods Total Mileage Gross Revenues Payroll Maintenance No. of Vehicles Page 1 of 6

3 5. If this is a start-up operation, please describe your previous tranportation experience: 6. Please describe fully any personal use permitted of the vehicle(s) scheduled in this application: 7. Are members of a driver s family or anyone else permitted to drive any of the vehicle(s) scheduled in this application? Yes No If yes, please describe fully: 8. Are all vehicles used exclusively for the purpose of transporting children? Yes No If No, please describe any other vehicle operation fully: 9. Do you contract with parents? Yes No If No, please state who you contract with: Please tell us about your drivers. 1. Complete Drivers Information Schedule attached for all drivers, including occasional use drivers (Back-up drivers, family members, etc.) 2. Current total number of permanent drivers: Back up drivers: 3. During the last 12 months, how many drivers have you Replaced? Added? Please tell us about your vehicles. 1. Complete equipment schedule form. 2. Are any vehicles ever parked at a driver s residence? Yes No If yes, please describe. 3. Are any vehicles equipped with a trailer hitch? Yes No If yes, please describe why. Please tell us about your maintenance program (Supplemental to information requested on page 1.). 1. How is the maintenance of vehicles controlled? 2. Describe written guidelines used to insure safe vehicle operative condition. 3. Do you service your own vehicles? Yes No If No, who does? 4. When are the vehicles normally serviced? 5. Describe fully what contingency plans are followed if a vehicle cannot be operated: Page 2 of 6

4 6. Does your vehicle maintenance program include the following? A service record for each vehicle (attach copy) Yes No Controlled inspection frequency Yes No Vehicle daily condition report (attach copy) Yes No How often are these various reports reviewed? Please tell us about your safety program 1. Please provide the following information for the person in your organization who is responsible for safety. Name: Title: Training/Background: Years Experience: 2. Are all passengers required to use seat belts? Yes No If No, please explain: 3. How is the operation of vehicles supervised? 4. What procedures are followed to reduce the likelihood of accidents? 5. In the event of an accident, what procedures are followed to control the effects and avoid recurrence? Please tell us about your insurance history. 1. Please provide the following information for your current and past four (4) policy periods, and indicate if this experience reflects transportation of children or some other transportation operation: Current Policy Period Prior Four Policy Periods Insurance carrier Policy effective and expiration dates Liability limit Annual Premium Auto Liability Physical Damage Total Incurred Losses Auto Liability Physical Damage Valuation Date Type of operation Page 3 of 6

5 2. Has your insurance ever been obtained through an Assigned Risk Plan? Yes No If yes, please explain when and why. 3. Has any company, during the past three (3) years cancelled or refused to renew your automobile insurance coverage? Yes No If yes, please explain. 4. If you are an experienced provider of transportation to children or have any current tranportation operations, please attach currently valued loss runs from your insurance carriers for each of the past three (3) policy periods. If loss runs are not available, please state the reasons why and attach to this application a signed claims statement specifying claims as to type, amount paid and amount reserved for each of the past three (3) policy periods. Also, please provide details on any loss occurrences that exceeded $25,000 or involved a fatality or serious injury. THIS INFORMATION IS MANDATORY. Please tell us the types and amounts of insurance coverage you require. Type of Coverage Limits Automotive Liability (includes $500,000 per occurrence Bodily Injury/ Property Damage $1,000,000 per occurrence Liability, non-owned and hired Other $ auto, minimum statutory limits for uninsured/under-insured motorists and no-fault coverage where required) Physical Damage - Comprehensive NOT APPLICABLE } Deductible Physical Damage - Collision $250 per occurrence (minimum) (Please note collision coverage $500 per occurrence cannot be purchased alone. $1,000 per occurrence It can only be purchased NOT APPLICABLE Other $ with Comprehensive Coverage.) Page 4 of 6

6 Please read the following statement carefully before you sign this application. I hereby apply for the insurance indicated and represent that: I have read this application The statements hereon are correct The limits and coverages requested were selected by me. I also understand and agree that: The completion of this application creates no express or implied obligation on the part of Lancer Insurance Company, its subsidiaries, affiliates or manager to offer a quotation or provide insurance as requested in this application. Lancer Insurance Company or its manager is authorized to investigate the driving records of me and all other drivers of my van. Lancer Insurance Company or its manager may request a consumer report in connection with this application and that, upon my request, I will be informed if a consumer report was requested, and if such a report was requested, I will be informed of the name and address of the consumer reporting agency that furnished the report. MANDATORY STATE FRAUD WARNINGS COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MIS- LEADING 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 CLAIM- ANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY- HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSUR- ANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. FLORIDA: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OF AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. 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. KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY IN- SURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CON- TAINING 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. NEW JERSEY: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMA- TION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFOR- Page 5 of 6

7 MATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUB- JECT TO CIVIL FINES AND CRIMINAL PENALTIES. PENNSYLVANIA: 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 MATERIALLY FALSE INFORMATION, OR CON- CEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. MAINE, TENNESSEE, DISTRICT of COLUMBIA, & VIRGINIA: IT IS A CRIME TO KNOW- INGLY 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. ARKANSAS and LOUISIANA: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. OHIO and OKLAHOMA: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSUR- ANCE FRAUD, A CRIME. ALL OTHER STATES: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY IN- SURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL IN- SURANCE OR STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOW- INGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MO- TOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATE CLAIM FOR EACH VIOLATION. I certify that the information contained on this application is true and accurate to the best of my knowledge. Applicant s Signature*: Title: Company: Date: * BY SIGNING THIS APPLICATION, YOU GIVE US THE RIGHT TO EXAMINE OR INSPECT FILES, RECORDS, DOCUMENTS AND EQUIPMENT IN ORDER TO DETERMINE THE ACCURACY OF THE INFORMATION STATED HEREIN. THANK YOU FOR YOUR COOPERATION, PLEASE ALLOW DAYS FOR PROCESSING THIS APPLICATION. Page 6 of 6

8 # of Yrs. Driving a Van DRIVERS INFORMATION SCHEDULE Name Indicate type of Driver (P-Primary, B-Backup) Date of Birth Driver s License Number State of Issuance

9 Radius Cost New EQUIPMENT SCHEDULE Unit # Year Make VIN / Serial # (Please attach a copy of each van s registration.) Leased/ Owned Principal Use 1. Vanpool 2. Spare 3. Other Seat Capacity Garage Location City & State Unit # Route Starting Point Route Ending Point Loss Payee (if any)