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Municipal Entity Underwriting Application

Current Carrier

Unique Extensions or Exclusions

1.

If your entity desires an SIR program, does your entity have a preferred Third Party Administrator (TPA)?

If yes, complete the Third Party Administrator Information section.

 Yes

 No

2.

Are employees involved in operating entity-owned vehicles

If yes, complete the Automobile Liability Information section if this coverage is being requested.

 Yes

 No

3.

Summary of Automobile Exposures

Type

Contracted

# Owned

# Leased

Total

Private Passenger Autos

 Yes  No

Private Passenger Trucks

Non-Emergency

Vans, Pickups & Light Trucks (GVW  0 to 10,000)

 Yes  No

Medium Trucks (10,001 to 20,000 lbs GVW)

 Yes  No

Heavy ( 20,001 to 45,000 lbs GVW)

 Yes  No

Extra Heavy (over 45,001 lbs GVW)

 Yes  No

Tractor/Trailer

Heavy ( 0 to 45,000 gross combined weight)

 Yes  No

Extra Heavy (over 45,000 gross combined weight)

 Yes  No

Fire Department

Fire Cars

 Yes  No

Ladders

 Yes  No

Engines

 Yes  No

Rescue Trucks

 Yes  No

Emergency Vehicles

Ambulances/Ambulettes

 Yes  No

Police Department

Cars

 Yes  No

Motorcycles

 Yes  No

Vans/Special Operations Trailers

 Yes  No

Emergency Service Vehicles

 Yes  No

4.

Do you have a vehicle maintenance program for all of your vehicles?

 Yes

 No

5.

Do you utilize a safety program?

 Yes

 No

6.

Do you request MVRs on all drivers?

If yes, how often?  

 Yes

 No

7.

Is any coverage provided for any non-owned vehicles?

If yes, please explain.  

 Yes

 No

8.

Do you provide transportation services to any public agency, non-profit organization, or community group?

If yes, provide details.  

 Yes

 No

Unisured Motorists  Information

If N/A, Uninsured Motorists Rejection Notice Must Be Signed (Where Applicable As A State Mandate)

n/a

1.

Per Accident Limit

2.

Deductible or Retained Limit

23 of 3410/23/2007

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