Application for Excess Automobile Liability | Paratransit Insurance Company

Name of Firm:*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax:

Years in business under present ownership:*

Business Type:*

Corporation
Sole Proprietorship

Approximate net worth:*

Enclose Financial Statement:*

Drop files here or

This is document support for approximate net worth. Files accepted are pdf, jpg, png, doc, docx, xls and .xlsx. You can send up to 3 documents.

Area of Operations:*

Type of Operations:*

Radio Dispatch Taxi
Taxi - No Radio
Limousine
Service Exec. Car
Airport Limousine
Handicap
Other

How many radio dispatch taxi operations?*

How many taxi - no radio operations?*

How many limousine operations?*

How many service exec. car operations?*

How many airport limousine operations?*

How many handicap operations?*

How many other operations?*

Other Operations:*

Total Number of Authorized Permits:*

Method of Operation(s):*

Commissioned Driver (employee) units
Leased Driver units
Driver/Owner units

Number of Commissioned Driver units:*

Number of Leased Driver units:*

Sub-leasing Permitted?*

Yes
No

Number of Units Sub-leased:*

Are there any leased or sub-leased units taken home when off duty?*

Yes
No

Number of Driver/Owner units:*

Second driver allowed?*

Yes
No

Number of Second Driver units:*

Are all driver records, MVR's, etc. approved by management?*

Yes
No

Is firm certified as an authorized self-insured?*

Yes
No

Limits:

Is a claim escrow account maintained?*

Yes
No

What Bank?*

Will claims be handled by an Adjusting Firm?*

Yes
No

Name of Adjusting Firm:*

Address of Adjusting Firm:*

Street Address Address Line 2 City State ZIP Code

Name of Attorney who will handle Litigations:*

First Last

Address of Attorney that will handle Litigations:*

Street Address Address Line 2 City State ZIP Code

If coverage is purchased, you agree to have your attorney furnish quarterly reviews of all quarterly claims that are six months or older and which occurred under the current policy or under previous policies if insured through the same company.

Are MVR's obtained on all drivers?*

Yes
No

Paratransit requires MVR's be ordered every year. However, every 6 months is preferable.

Are prospective drivers required to attend company-sponsored driver training school?*

Yes
No

Describe training and those requirements:*

Is a formal safety program in effect?*

Yes
No

Describe formal safety program:*

What procedures are followed by your firm when a driver is involved in a chargeable accident or receives a ticket?*

Do you own a maintenance garage?*

Yes
No

How is maintenance handled? Who does the maintenance work?*

Is there any program of regular vehicle inspection and maintenance other than city or state inspection?*

Yes
No

Please describe how it's endorsed:*

If cabs are driver owned, is an inspection and maintenance program compulsory?*

Yes
No

Please describe how it's endorsed:*

Current Insurance Carrier:*

Current Insurance Carrier Premium:*

Current Insurance Carrier Limits:*

Liability Limits & UNinsured/UNDERinsured Motorist Coverage

I wish a quote as follows:

Please check all that apply:*

Liability Limits
Retained or SIR Limit
I wish to reject uninsured Motorist Coverage if my state permits me to do so.
I wish to reject underinsured Motorist Coverage if my state permits me to do so.
Quote uninsured Motorist Coverage for minimum limits required in my State of Domicile.
Quote underinsured Motorist Coverage for minimum limits required in my State of Domicile.
Quote uninsured Motorist Coverage for minimum limits for Policy limits.
Quote underinsured Motorist Coverage for minimum limits for Policy limits.

Liability Limits Amount:*

Retained or SIR Limit Amount:*

Off-Duty Coverage

Quote off-duty coverage for lessee or driver-owner. (Maximum limit is $100, 000)

LESS the Retained Limit?*

Yes
No

What Limit?*

Attachments

In order to be considered for quotation, you must include the following with this application:

Financial Statement
List of all owned or all operated units to include year, make, VIN or I.D. number. (AU units with seating capacity of over 5 seats must be identified and the number of seats given.)
List any units to be excluded from this quotation.
Drivers List and Current MVR's.
Loss Run for prior 3 years.

Additional Documents Upload:

Drop files here or

Agreements

It is specifically understood and agreed that this application is made to a Risk Retention Group. A Risk Retention Group may not be subject to all of the Insurance laws and regulations of your state. State Insurance Insolvency Guaranty Funds are not available for a Risk Retention Group.*

I agree
I do not agree

It is further agreed that I (we) hereby make application to become a member of Paratransit Insurance Company, a Mutual Risk Retention Group.*

I agree
I do not agree

Your Name:*

Please electronically sign this application.

First Last

Email:*

A copy of this application will be sent to this address.

Enter Email Confirm Email

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