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1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?
VEH # NAME OF OTHER OWNER
VEH # NAME OF OTHER OWNER
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2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS?
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3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?
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4. ARE ANY VEHICLES LEASED TO OTHERS?
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5. ANY CAR MODIFIED / SPECIAL EQUIPMENT? (Include customized vans / pickups)
VEH # DESCRIPTION COST $
VEH # DESCRIPTION COST $
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6. ARE ICC (Interstate Commerce Commission), PUC (Public Utility Commission) OR OTHER FILINGS REQUIRED?
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7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?
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8. ANY HOLD HARMLESS AGREEMENTS?
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9. ANY VEHICLES USED BY FAMILY MEMBERS? IF SO, IDENTIFY.
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10. DOES THE APPLICANT OBTAIN MVR (Motor Vehicle Record) VERIFICATIONS?
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11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD?
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12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION?
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13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION?
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14. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?
Applicable only in Kansas: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO INSURERS:
1. A speeding violation of up to six (6) mph in an area with a posted speed limit from 30–54 mph
2. A speeding violation of up to ten (10) mph in an area with a posted speed limit from 55–75 mph
DRV # DATE (MM/DD/YYYY) TYPE
PLACE (City, State) # YRS REV
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15. HAS AGENT INSPECTED VEHICLES?
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16. ARE ALL VEHICLES TO BE INCLUDED IN THIS POLICY PART OF A FLEET?
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17. DO YOU HAVE ELECTRONIC MONITORING DEVICES THAT RECORD AND TRANSMIT DATA IN ANY OF YOUR VEHICLES?
If "YES", what percentage of vehicles in your overall fleet are monitored (1 - 100%)
%
Please indicate how you utilize the devices (check all that apply):
Monitor Driver SafetyTrack Fuel ConsumptionMonitor Vehicle MaintenanceMileage TrackingLocation TrackingNavigation
Describe:
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DESCRIPTION OF GARAGE / STORAGE LOCATIONS
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MAXIMUM DOLLAR VALUE SUBJECT TO LOSS
$
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