TOW TRUCK PROGRAM – INSURANCE APPLICATION

Attach with State Specific Acord Selection pages for UM, PIP, TERRORISM, ETC.


P O Box 537 – Pooler, Ga. 31322
912-450-7500 – Fx: 912-450-7707 / Agency:
Producer:
Address:
Email:
Phone:
Date:
Section 1: APPLICANT INFORMATION
Applicant’s Legal Name: / Effective Date of Coverage:
Mailing Address: / City: / County: / State / Zip
Individual Corp. LLC
Partnership Joint Venture Other (describe) / Years in Business:
Owners Name: / Inspection Contact:
Phone: / Federal ID Number OR SS#:
Section 2: LOCATION INFORMATION
Number / Street, City, County, State, Zip Code / Use of Location / How Occupied

Section 3: Auto Liability Coverage:

1. Limit: $300,000 $500,000 $750,000 $1,000,000 (Combined Single Limits)

2. No Fault /Personal Injury Protection: $ Property Protection (Michigan only): $

3. Medical Payments: $

4. Uninsured Motorist: $ Underinsured Motorist (Same Limit as Uninsured Motorist)

5. Hired Car Non-Owned Auto

6. Dealer/Transporter Tags: How Many? Tag Number: , , , .

7. Describe the use for each tag.

Please follow the instruction listed below for additional coverage:

Physical Damage Coverage: Complete coverage for each individual vehicle on the vehicle schedule.

On Hook Cargo Coverage: Complete coverage for each individual vehicle on the vehicle schedule.

Miscellaneous Towing and Recovery Equipment Coverage: Provide a separate schedule of the items to be covered; the list should include serial numbers, value and deductible for each item to be covered. (The minimum deductible is $500.)

Total Gross Annual Sales:
Section 4: Operational Revenue: Provide the percentage of revenue from each of the following operations:
Operation / Percentage of Revenue / Complete Section
Towing / % / 2,3,4,5,6,7,8,9,10,11,12,14,15,16,18,19,20
Voluntary Repossession / % / 15 -Attach Repo Supplement if more than 15%
Involuntary Repossession / % / 15 –Describe operations on remarks page
Auto Transporting (car haulers) / % / 17
Trucking/Equipment Hauling / % / 18
Trucking/Other: / % / 18
Repair Shop / % / 19
Body Shop Repairs / % / 20
Service Station / % / 14
Rental Operations / % / 13
Salvage/Used part sales / % / 16
Tire Sales / % New % Used % Recapped / Gross Sales:
Fire Works Sales/Storage / % / If any, Property & GL is declined
Lien Car Sales / % / Number of cars sold per month:
Auctions / % / Number held annually:
Part Sales – New / %
Parking/Storage / %
Other: Specify: / %

Financial History: In the past three years has the company or its owners filed for bankruptcy, financial reorganization or had any liens placed against it. Yes No

Section 5: Safety Management:

1. Name and Title of person in charge of the Safety Program

2. Do you have a Written Safety Program? Yes No

3. How often do you hold safety meetings? Weekly Monthly Quarterly

4. Are ALL trucks equipped with annually inspected fire extinguishers? Yes No

5. Do you have a written Driver Training Program?Yes No

6. Do you have a written vehicle take-home policy?Yes No

7. Do you have a drug-testing program in place?Yes No

Section 6: Maintenance:YesNo

1. Do you maintain maintenance logs on each vehicle?

2. Do you perform the routine maintenance on your equipment?

3. If YOU DO NOT perform the maintenance who does?

4. Are they Professionally Certified as Mechanics?

5. Are your drivers in any way responsible for the cost of the maintenance of your equipment?

6. Do your drivers perform daily maintenance checks on ALL vehicles?

7. Are your vehicles subject to ANNUAL INSPECTION by the STATE?

Section 7: Driver Management Section:YesNo

1. Pre-hire Screening:Do you obtain a Motor Vehicle Record Report (MVR) on each driver prior to hiring?

2.Do you require job references?

3.Do you check job references prior to hiring?

4.Do you road test ALL drivers prior to hiring?

5. Driver Management: Do you obtain an MVR on ALL company drivers at least on an Annual basis?

6.Do you maintain driver files on ALL drivers including copies of tickets and the MVR?

7.Do ALL your drivers meet the federal, state and local license classification requirements?

8.Do you have a Written Disciplinary/Termination policy?

9.Do you have a Written Accident Review Policy?

10.Do you issue any employee or independent contractor a 1099?

11.Do you carry Workers Compensation Insurance for ALL your employees?

12. How are drivers compensated? Hourly Wage Salary Commission 1099

13. How many drivers quit or were fired last year? How many did you hire last year?

14. Do you require your drivers to take outside training courses?

15. If yes, what driver training do you provide for your drivers?

Section 8: General Operations: YesNo

1. Operations:Do you lease vehicles from other individuals or companies?

2.Do you lease vehicles to other individuals or companies?

3.Do you own or lease any cranes?

4.Do you hire SUB-CONTRACTORS at any time?

5.Do you have any additional vehicles owned or leased by your company NOT on this schedule?

6.Do your vehicles travel outside of a 200-mile radius on a Regular basis?

7. Are the following procedures or items required?

8.Do you require the use safety chains on every tow?

9.Do you require the use of wheel-lift straps on every tow?

10.Do you require the use of vehicle-towing lights onevery tow?

11. Please breakout the per trip mileage for your fleet: 0-50 Miles %, 51-200 Miles %, Over201 Miles %

Section 9: Regulatory Filings: (To aid in the processing of a filing please submit a copy of the prior filing we are replacing)

YesNo

1. Filings: Do you require a DOT or State Filing?

2. Do you require an MCS-90 endorsement?

3. Haz Mats: Do you ever perform secondary tows of hazardous materials?

4. Do you ever move hazardous materials on a primary haul basis?

5. MC/DOT NUMBER:STATE DOCKET NUMBER:

6. Are any additional filings required?

1

Section 10: GENERAL LIABILITY: (Same limit applies to all locations) (Aggregate limit is 1, 2, or 3 times the Occurrence limit)
1. Occurrence Limit: $300,000 $500,000 $750,000 $1,000,000Aggregate Limit:
Location 1: General Liability Section: Complete the following for all operations: Amounts are for Gross annual only
  1. Trucker/TowingGross Payroll:
  2. Auto Repair and Body Shops (10073)Gross Sales:
  3. Roadside Assistance (10073) Add sales to Auto repair if there is a shopGross Sales:
  4. Parking/Storage (46622) Storage area including inside Garage)Storage Area:
  5. Parking/Storage (46604) (use this code if a storage charge is made)Gross Sales:
  6. Buildings/Office (applies if no storage or repair)Square Feet:
  7. Vacant Building (68606) Square Feet:
  8. Vacant Land (49451)Square Feet:
  9. Stores (13673) If any cooking submit with Restaurant supplementGross Sales:
  10. Gasoline Stations _ Self Service (13454)Annual Gallons:
  11. Gasoline Stations _ Full Service (13453)Annual Gallons:
  12. Tire Dealer (18616) If installed only add sales to auto repairGross Sales:
  13. Auctions (91179) Lien car salesGross Payroll:
  14. Auto Dismantling/Salvage (91190) Gross Payroll:
  15. Other: Specify: Rating Basis:

Location 2: General Liability Section: Complete the following for all operations: Amounts are for Gross annual only
  1. Trucker/TowingGross Payroll:
  2. Auto Repair and Body Shops (10073)Gross Sales:
  3. Roadside Assistance (10073) Add sales to Auto repair if there is a shopGross Sales:
  4. Parking/Storage (46622) Storage area including inside Garage)Storage Area:
  5. Parking/Storage (46604) (use this code if a storage charge is made)Gross Sales:
  6. Buildings/Office (applies if no storage or repair)Square Feet:
  7. Vacant Building (68606) Square Feet:
  8. Vacant Land (49451)Square Feet:
  9. Stores (13673) If any cooking submit with Restaurant supplementGross Sales:
  10. Gasoline Stations _ Self Service (13454)Annual Gallons:
  11. Gasoline Stations _ Full Service (13453)Annual Gallons:
  12. Tire Dealer (18616) If installed only add sales to auto repairGross Sales:
  13. Auctions (91179) Lien car salesGross Payroll:
  14. Auto Dismantling/Salvage (91190) Gross Payroll:
  15. Other: Specify: Rating Basis:

Location 3: General Liability Section: Complete the following for all operations: Amounts are for Gross annual only
  1. Trucker/TowingGross Payroll:
  2. Auto Repair and Body Shops (10073)Gross Sales:
  3. Roadside Assistance (10073) Add sales to Auto repair if there is a shopGross Sales:
  4. Parking/Storage (46622) Storage area including inside Garage)Storage Area:
  5. Parking/Storage (46604) (use this code if a storage charge is made)Gross Sales:
  6. Buildings/Office (applies if no storage or repair)Square Feet:
  7. Vacant Building (68606) Square Feet:
  8. Vacant Land (49451)Square Feet:
  9. Stores (13673) If any cooking submit with Restaurant supplementGross Sales:
  10. Gasoline Stations _ Self Service (13454)Annual Gallons:
  11. Gasoline Stations _ Full Service (13453)Annual Gallons:
  12. Tire Dealer (18616) If installed only add sales to auto repairGross Sales:
  13. Auctions (91179) Lien car salesGross Payroll:
  14. Auto Dismantling/Salvage (91190) Gross Payroll:
  15. Other: Specify: Rating Basis:

Section 11: Garage Keepers Coverage: Please provide the details of each storage facility.

1. Coverage Type: Legal Liability Direct Primary (available only if required by contract – attach copy)

Loc.1. Limit: $Address: City: State: Zip:

Loc.2. Limit: $Address: City: State: Zip:

Loc.3. Limit: $Address: City: State: Zip:

Storage Facility:Locations:123

YesNoYesNoYesNo

2. Do you provide public parking or storage at any of you locations?

3. Completely fenced

4. Completely lighted at night

5. Surveillance camera equipped

6. Is the facility equipped with Intrusion alarm?

7. Lot attended during business hours

8. ARMED Security guards on duty during the day or at night?

9. Fire extinguishers are accessible at each yard

10. Customers’ keys are kept locked in a secure location

Garage Keepers Operations:Locations:123

YesNoYesNoYesNo

11. Do you pick up or deliver customers’ vehicles by driving the vehicle?

12. Do you maintain the proper type and number of fire extinguishers?

Section 12: Towing:

1. How many tows do you perform on average per month?

2. How many employees are involved in this operation?

3. Indicate below the various types of towing you perform:

4. Private Property (illegal parking violator removal)YesNo8.Motor Club towingYesNo

5. Municipality, Highway or Turnpike RotationYesNo9. Towing for banks or finance companiesYes No

6. Voluntary RepossessionsYesNo10.Towing for your own garage/body shopYesNo

7. Heavy Duty Commercial Towing and RecoveryYesNo11.Involuntary RepossessionsYesNo

Dispatching:

12.Are your tow trucks equipped with Scanners?YesNo

13.Do you participate in any “Chase” or first on the Scene towing?YesNo

14.Do you require each tow performed by your company to be dispatched by your office dispatcher?YesNo

Section 13: Rental Operations: Please provide the details of this operation in a narrative on the remarks page.

1. Do you operate a Rental or Leasing operation at any location scheduled on this policy?Yes No

2. Do you have a general liability policy in place covering this operation?Yes No

Section 14: Service Station Operations: Please provide the details of this operation in a narrative presented with this application.

1. Do you have a general liability policy in place covering this operation?Yes No

2. Do you have underground gas storage? Yes No

3. Do you maintain pollution coverage on all storage tanks above ground and/or below ground?Yes No

4. Do you sell Alcoholic Beverages?Yes No

Section 15: Voluntary and Involuntary Repossession: provide the details of this operation in a narrative on the remarks page.

1. Who issues the assignment to pick up a car?

2. Are the debtors’ notified in advance and agreeable to the voluntary surrender of the vehicles?YesNo

3. Do you perform Involuntary Repossessions?YesNo

4. If Repo sales are more than 15% of total sales attach with Repo Supplemental Application

Section 16: Salvage, Dismantlers Scrap Metal or Junkyard: Provide the details of this operation on the remarks page. Locations: 1 2 3

YesNoYesNoYesNo

1. Do you have a General Liability Policy in place covering this operation?

2. Do you or have you ever owned or leased a crushing machine?

3. Do you allow third party vendors to perform crushing on your property?

4. Do you allow customers to pull parts from the stored autos?

5. Do you retain a copy of the sales receipt for all parts sold?

6. Does your receipt contain a “Sold as is Warranty”?

7. How many employees do you have involved in this operation?

*** Please provide a SAMPLE COPY of a receipt with the “SOLD AS IS WARRANTY” wording with this application

Section 17: Auto Transporting/Car Hauling
ISO radius applies: 50 miles; 200 miles; Long distance (for long distance we need all destinations).
List all Destinations Regularly or frequently traveled or attach copies of last two quarters of IFTAs
Any Freight Brokering? Yes No / Haul Boats? Yes No
Use Trailer Interchange Agreements? Yes No / Haul Campers/Mtr Homes? Yes No
Any drive-away work? Yes No / Haul other Freight? Yes No
Any transporter plates? Yes No / Auto Dealer? Yes No
Any vehicle leased/loaned/rented to others? Yes No / Auto Repair/Body Shop? Yes No
Any employees/owner operators not listed? Yes No / Own or sponsor a car for racing? Yes No
Any owned/leased vehicles not listed? Yes No / Storage Lot/Terminal? Yes No
Truckers Payroll (Excluding Drivers) (If none show state minimum)

Section 18: Truck/Equipment Hauling:Please provide the details of this operation in a narrative presented with this application.

1. Do you have contracts to haul goods for specific customers?YesNo

2. Are all drivers performing this work CDL Class “A” licensed drivers?YesNo

3. Do you haul, transport or set up Mobile Homes?YesNo

4. What is the MAXIMUM distance traveled? Miles

5. How many of your drivers are involved in this operation?

6 What commodities do you haul?

Section 19: Service Garage / Auto Repairs: Location: 123 4 Annual Gross Sales: Yes No Yes No Yes No

1. Do you sell auto parts? New Used

2. Do you sell “third party” remanufactured parts?

3. Does your sales receipt contain a “Sold, as is Warranty”

4. Do you sell and install tires?New Used

5. Do you sell recapped tires for private or commercial vehicles?

6. Do you perform any type of welding at any location?

7. Do you have any dogs on your premises during or after hours?

8. Do you have gas sales at any location scheduled on this policy?

9. Are there above ground and/or below ground storage tanks at any location?

10. Do you own or lease out limousines, vans or buses?

11. Do you own or operate a car wash at any location?

12. Do you restrict the public from entering your garage work area?

13. Do you provide an area for customers to wait while their vehicle is repaired?

14. Do you operate a convenience store at any location?

15. Is the facility inspected by a governmental agency on an annual basis?

16. Do you retain written records on all repairs performed by your operation?

17. Are repairs performed on private passenger autos?

18. Are repairs performed on commercial autos or heavy equipment?

19. Do you own, sponsor or work on “race cars”?

20. Are ALL of your service and repair mechanics professionally certified?

21. How many mechanics do you have working at each location?

22. What types of repairs do you perform? Minor Repairs Major Repairs (Rebuild Engines, Transmission)

23. What types of vehicles do you repair Private Passenger Commercial AutoCommercial Equipment

24. How many service bays do you have? How many of those bays have a lift system for hoisting automobiles?

26. Please indicate if you Sell or Service any of the following:

ATV’s Motorcycles Gray Market Vehicles Boats

Kit Cars RV’s Van Conversion Stretch Vehicles

Section 20: Service Garage / Auto Body Shop: Location: 123 Yes No Yes No Yes No

1. Do you have a paint booth?

2. Do you have a UL approved Paint Booth?

3. Do you paint cars outside of the booth?

4. Do you perform welding as part of the repair?

5. Do you have a frame-straightening machine?

6. How many employees do you have involved in this operation?

7. What company manufactured the Frame Straightening Machine?

Driver Information

Applicant:

Complete the information below for ALL DRIVERS.

No. / Name / DOB / Drivers License Number / ST / Years Exp / Hire Date / Driving Record
1
2
3
4
5
6
7
8
9
10
11
12

Has every possible driver been identified including part time? Yes No

VEHICLE SCHEDULE - ISO radius applies: 50 miles; 200 miles; Long distance (for long distance we need all destinations).

Vehicle # 1
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 2
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 3
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 4
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 5
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 6
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 7
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Vehicle # 8
Year / Make / Model / Body Type / GVW / Full Vehicle Identification number
Garage Location # / Cost New / Stated Amt. / Comp Ded / Collision Ded / On-Hook/Cargo Limit / Cargo Ded
Use of vehicle / Describe Tow/Specialty Equipment (Rotator, Etc) / Radius
Dealer/Transport Tags
If more than 4 list in remarks / How many? Tag Number: , , ,

Section 22: Insurance History: ** (If you are a Missouri applicant SKIP questions 1, 2 and 3 of this section)

1. In the last twelve months, has your insurance been canceled for NON PAYMENT of premium?Yes No