Business Auto Supplemental Questionnaire

Name

Website

Address

Do you maintain offices or operations in other states?
YesNo
If yes, please list states

Person to contact

Title

Telephone

Email

Date Established

License #

Have you ever operated under any other name?
YesNo
If yes, what names

Historical Business Auto Insurance Policy Information

A.

Prior Policy Year

Insurance Company

Number of Vehicles Insured

Total Premium

B.

Prior Policy Year

Insurance Company

Number of Vehicles Insured

Total Premium

C.

Prior Policy Year

Insurance Company

Number of Vehicles Insured

Total Premium

D.

Prior Policy Year

Insurance Company

Number of Vehicles Insured

Total Premium

Have any auto liability claims been reported to your auto insurance carrier over the last 5 years?
YesNo
If YES, please attach prior carrier insurance company loss report a/k/a loss run for the past 5 years

Has your auto insurance ever been cancelled or non renewed for any reason?
YesNo
If Yes, please provide reason for cancellation or non-renewal below:

Underwriting Questions

Are drivers license abstracts checked prior to allowing employees to drive a company vehicle?
YesNo

Are drivers license abstracts checked for all employees who are eligible to use a company vehicle at least annually?
YesNo

Are vehicles garaged or used outside of the United States?
YesNo

Are any drivers under the age of 21?
YesNo

Are any vehicles garaged or registered in the State of Massachusetts?
YesNo

Does the firm have a written driver safety program?
YesNo

Do over 50% of employees use their autos in the business?
YesNo

Does a vehicle maintenance program exist?
YesNo

Are scheduled vehicles used by family members?
YesNo

Are any owned or leased vehicle NOT scheduled on this application?
YesNo

Does the firm have a driver training program?
YesNo
If yes, please describe below

Are any vehicles armored?
YesNo

Do operations include courier or escort services?
YesNo

Does the firm provide alarm response services?
YesNo

Eligible Drivers. Are any employees authorized to drive company vehicles with any of the following MVR violations:
Click here if NO for allDriving while intoxicated or under the influence of drugsNegligent homicide arising from the use of a motor vehicleEluding or attempting to elude a police officerUsing a motor vehicle in the commission of a felonyMore than 3 moving violations in the past three (3) yearsOperation of vehicle during a period of suspension or revocationRefusing a drug or alcohol testAggravated assault with a motor vehicleSpeeding ContestPermitting an unlicensed person to drive a vehicleHit and Run AccidentReckless driving

Vehicles - Does the firm own or operate any of the following types of vehicles?
Click here if NO for allTaxiLimousineBusVan PoolCourtesy VehicleFuel, Gas, Oil or other Hazardous MaterialsDrive or Haul Away Vehicles and OperationsIndividually Owned VehiclesFarm VehicleMobile HomesTrucker or Bobtail OperationsAuto Dealer or Dealer Plated VehiclesAmbulance, Medic or EMT VehiclesDriver Training VehicleFire Trucks or Fire Response VehiclesVehicles rented or leased to Others

Signature Section

Principal, Owner or Officer Signature

Name

Title

Date

Garage Locations - we need the garage addresses of ALL rated vehicles

Loc # 1

Address

City

ST

Zip

Loc # 2

Address

City

ST

Zip

Loc # 3

Address

City

ST

Zip

Loc # 4

Address

City

ST

Zip

Vehicle Schedule 1

Year

Make

Model

Vehicle ID Number

Cost New

Garage City/St

Zip Code

Vehicle Schedule 2

Year

Make

Model

Vehicle ID Number

Cost New

Garage City/St

Zip Code

Vehicle Schedule 3

Year

Make

Model

Vehicle ID Number

Cost New

Garage City/St

Zip Code

Vehicle Schedule 4

Year

Make

Model

Vehicle ID Number

Cost New

Garage City/St

Zip Code

Driver Schedule 1

Last Name

First Name

Mid Int.

ST Lics.

DOB

Drivers License Number

Expiration Date

Job Function

Driver Schedule 2

Last Name

First Name

Mid Int.

ST Lics.

DOB

Drivers License Number

Expiration Date

Job Function

Driver Schedule 3

Last Name

First Name

Mid Int.

ST Lics.

DOB

Drivers License Number

Expiration Date

Job Function

Driver Schedule 4

Last Name

First Name

Mid Int.

ST Lics.

DOB

Drivers License Number

Expiration Date

Job Function