/ APPLICATION FOR VANPOOL OWNER OPERATORS
370 West Park Avenue, P. O. Box 9004, Long Beach, NY11561
(516) 431-4441  FAX (516) 889-9872 
IMPORTANT INSTRUCTIONS:
All information requested in this application should be TYPEWRITTEN or PRINTEDin ink.
1. / This application cannot be processed unless answered completely and signed by the Named Insured.
2. / This application cannot be processed unless the following documents are completed:
  • Equipment Schedule (attached) – include a copy of each van’s registration
  • Driver’s Information Schedule (attached)
  • Currently valued insurance company Loss Runs for the past five (5) years

3. / Please attach copies of any written forms and procedures followed by the Named Insured, for example:
  • Driver’s Criteria
  • Maintenance Program
  • Safety Program

4. / The effective date of coverage requested under this application is
5. / A quotation for the coverages requested under this application is needed no later than
6. / Please attach a photo of your van(s).
A)Please tell us about yourself.
1. / Business Name (if any) :
2. / Your Name: / Date of Birth:
3. / E-mail Address: / Website:
4. / Named Insured is: / Corporation Partnership Sole Proprietor Other
5. / FEIN:
6. / Address:
Street / Apt. # / City / State / Zip Code
7. / Home Phone: / ( ) / Business Phone: / ( ) / Cell Phone: / ( )
8. / Occupation: / Employer:
9. / Employer's Address:
Street / City / State / Zip Code
10. / How many years with current Employer?
11. / Normal Daily Work Schedule: / : AM PM to / : AM PM
12. / Is this a start up operation? / Yes No If Yes, please describe any previous transportation experience (if any):
13. / How did you hear about Lancer's vanpool insurance program?
14. / Do you belong to any state or national vanpool associations/organizations? / Yes No
If Yes, please list:
15. / Do you or any member of your household own any other vehicles? / Yes No
If Yes, please specify the year, make and model of each:
16. / Do you own and/or operate any other type of transportation business? / Yes No
If Yes, company name: / Description:
B)Please tell us about your van.
1. / Is your vehicle a van? / Yes No / IfNo, please go no further. This is not the program for you.
2. / Year: / Make: / Model: / Vehicle ID #:
3. / In what state is your van registered? / Under what name is it registered?
4. / Passenger Capacity: / Current Odometer Reading:
5. / Where is your van parked during the day? / Garage Driveway Residential Street Other:
Provide Address:
Street / City / State / Zip Code
6. / Where is your van parked at night? / Garage Driveway Residential Street Other:
Provide Address:
Street / City / State / Zip Code
7. / Who provides maintenance services for your van?
8. / Is your van equipped with any anti-theft device(s)? Yes No If Yes, please describe:
9. / Do you followthe manufacturer's recommended servicing schedule for your van? / Yes No
If No, please explain:
10. / Is your van equipped with a trailer hitch? / Yes No / If Yes, please explain what the trailer hitch is used for:
11. / Is your van leased? / Yes No / If Yes, please provide the lessor's full name, address and telephone number:
( )
Name / Street / City / State / Zip Code / Telephone
12. / If purchased, was your van? New? Used? / Purchase price: $
13. / If any financing was involved in the purchase, please provide the full name, address and telephone number of the financing
institution:
( )
Name / Street / City / State / Zip Code / Telephone
C)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 any other authority? / Yes No / What form of evidence is required?
2. / Commuting: / How many round trip(s) do you make per day? / How many days per week?
How many miles per round trip? / Number of Pick Up/Drop Off Points:
3. / How many Passengers? / Attach a list of passengers with place of employment.
4. / Are all passengers required to use seat belts? Yes No If No, please explain:
5. / Is consumption of alcohol by passengers allowed on van? Yes No If Yes, please explain:
6. / Are any of your passengers handicapped or disabled? Yes No / If Yes, please explain:
7. / Is your van wheelchair accessible? / Yes No
8. / Personal Use: / Do you or does anyone else use your van for any personal reasons (i.e. errands, vacations, etc.)?
Yes No If Yes, please explain:
9. / Please estimate number of days/miles of personal use annually: Days Miles
10. / Community Activities: / Do you use your van for any community activities (i.e.church functions, scouting, athletic activities, etc.)?
Yes No If Yes, please explain use:
11. / Frequency: Daily Weekly Monthly Other
D)Please tell us about your insurance history.
1. / What insurance company (not insurance agency or broker) currently insures your van?
2. / What are your current coverages? / Liability Limit: / Premium:
Physical Damage
Comprehensive Deductible: / Premium:
Collision Deductible: / Premium:
3. / When does your current van insurance policy expire? / /
4. / Has any insurance company canceled or refused to renew your van insurance during the past three (3) years? Yes No
If Yes, please explain: (not applicable in Missouri)
5. / Have you ever been insured through a state automobile assigned risk plan? Yes No If Yes, please explain when and
why:
Attach five (5) years of loss runs, if applicable.
E) Please tell us the types and amounts of insurance coverage you require.
Type of Coverage / Liability Limits
Liability (includes Bodily Injury/ PropertyDamage, minimum statutory limits for uninsured/under-insured motorists and no-fault coverage where applicable) / Combined Single Limit (CSL)
$100,000 per occurrence
$300,000 per occurrence
$500,000 per occurrence
$1,000,000 per occurrence
Other / $
Type of Coverage / Physical Damage Limit / Physical Damage Deductible
Physical Damage - / The most we will pay for “loss" in any one / Comprehensive: / $250 $500
Comprehensive / "accident" is the least of: / $1,000 / Other $
Physical Damage - Collision / 1. / The actual cash value of the damaged / Collision: / $250 $500
(Please note collision coverage / or stolen property as of the time of the “loss"; / $1,000 / Other $
cannot be purchased alone. It / 2. / The cost of repairing or replacing the
can only be purchased with / damage or stolen property; or
Comprehensive Coverage.) / 3. / The amount shown in the Schedule.

VANPOOL Owner Operators Application (09/17) Page 1 of 8

Please tell us who drives your van when the van is operated as part of your vanpool.
Name / Address / Date
of Birth / Driver's License
Number / State of
Issuance / # of Years
Driving a Van
Please List Any Additional DriverWho Operates Van (If Not Listed Above) / Relationship / Date
of Birth / Driver's License
Number / State of
Issuance / # of Years.
Driving a Van
During the past three years, have any of the drivers listed above been involved in an automobile accident or convicted of a moving violation? Yes No
If Yes, please complete the following:
Driver / Date of
Accident/Violation / Description of Accident/Violation

VANPOOL Owner Operators Application (09/17)Page 1 of 8

Please read the following carefully before you sign this application
I hereby apply for the insurance indicated above and represent that:
1) I have read this application.
2)The limits and coverages requested were selected by me.
3) All statements herein are true and accurate, to the best of my knowledge, and no material facts have been suppressed ormisstated. I understand that misrepresentation or omission of material facts will be cause for cancellation and may void coverage.
4) By signing this application, I authorize the insurer to obtain copies of motor vehicle reports for underwriting the indicated insurance, as well as the right to examine or inspect files, records, documents and equipment in order to determine the accuracy of the information stated herein.
The completion of this application creates no express or implied obligation on the part of the insurer or its manager to offer a quotation or provide insurance as requested in this application. If the insurance is provided, the policy will only cover the vehicles listed within for the coverages agreed. You must immediately notify the insurer in writing if there is any change in your equipment or operations, and all accidents must be reported promptly regardless of severity or fault.
DISCLOSURE
In consideration with your application for commercial automobile insurance, we may review a credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of the insurance score. Your credit report/credit-based insurance score will not be used for any purpose other than the underwriting of the Commercial Automobile insurance policy for which you have applied.
Under no circumstances can the credit-based insurance score, the lack thereof, or the refusal to authorize the obtaining of a credit report or credit-based insurance score be a factor in determining your eligibility for commercial automobile insurance, including cancellation or nonrenewal, if a policy is ultimately issued.
I authorize Lancer Insurance Company to obtain a credit report, including but not limited to a credit-based insurance score based on personal information provided. This authorization is valid for future reports obtained for renewal policies with Lancer Insurance Company.
MANDATORYSTATE FRAUD WARNINGS
ALABAMA: “aNY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME ANDMAY BE SUBJECT TO RESTITUTION, FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.”
ARKANSAS: “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 andmay be subject to fines and confinement in prison.”
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 FOR insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.”
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.”
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.”
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 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.”
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 andmay be subject to fines and confinement in prison.”
MAINE: “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 denial of insurance benefits.”
MARYLAND: “Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime andmay be subject to fines and confinement in prison.”
NEW JERSEY: “Any person who includes any false or misleading information 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 information in an application for insurance is guilty of a crime andmay be subject to civil fines and criminal penalties.”
OHIO: “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 insurance fraud.”
OKLAHOMA: “WARNING: Any person who knowingly, and with intent to injure, 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.”
OREGON: “Any person who, WITH THE INTENT TO KNOWINGLY DEFRAUD AN INSURER, makes A WILLFUL OR intentional misstatement, MISREPRESENTATION, OMISSION OR CONCEALMEANT OF INFORMATION that is material to the risk INSURED may be GUILTY OF INSURANCE FRAUD. MISSTATEMENTS, MISREPRESENTATIONS, OMISSIONS OR CONCEALMENTS MUST EITHER BE FRAUDULENT OR MATERIAL TO THE INTERESTS OF THE INSURER IN ORDER FOR THE INSURER TO ASSERT A RIGHT TO REMEDY.”
PENNSYLVANIA: “Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.”
RHODEISLAND: “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 ANDMAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
TENNESSEE: “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.”
VIRGINIA: “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.”
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.”
WEST VIRGINIA: “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 andmay be subject to fines and confinement in prison.”
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 insurance company or other person files an application for commercial insurance or a 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, knowingly 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 motor 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 stated claim for each violation.”
Producer Signature / Named Insured Signature
Print Name of Producer / Print Name of Insured
Title / Title
Date / Date
Are you the incumbent producer? Yes No
Is this business sub-produced? Yes No If Yes, Sub Producer Name:
Sub Producer Address:
Tel: / Fax: / E-Mail Address:

VANPOOL Owner Operators Application (09/17)Page 1 of 8


/ 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 / Radius / Cost New
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Unit # / Route Starting Point / Route Ending Point / Loss Payee ( if any )
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

VANPOOL Owner Operators Application (09/17)Page 1 of 8