Business Auto Questionnaire

E-mail:  environmentaluw@berkleysum.com

Instructions	
•	Please print clearly or type.
•	If additional space is needed to answer any question, attach details on a separate sheet using the first Named Insured’s letterhead and reference the applicable section number.	•	This application must be signed and dated by an authorized Owner, Principal, Partner, Director or Risk Manager of the first Named Insured.
•	Answer all questions completely.  If any question(s) does not apply, enter “N/A” in the space provided.	
	
Request (select one)	  New	  Renewal	  Endorse	

Section 1.  Applicant Information 	
Applicant Name or Named Insured	     	
Address	     	
City	     	State	   	ZIP	     	
Name of Contact	     	Title	     	
Telephone	      	E-mail	      	
Fax	     	Website	     	
Federal Employee Identification Number (FEIN)	   -      	Company is	     	

Section 2.  Producer Information	
Producer	     			
Address	     	
City	     	State	   	ZIP	     	
Contact	     	Title	     	
Telephone	     	Fax	     	
Email	     	Website	     	
Agency License Number	     	License State	   	

Section 3.  Operations	
	Yes	No	
1.	Do you have any owned autos or any autos leased on a long-term basis?  (If not, please skip to question 3)			
2.	Do you have a written Fleet Safety Policy Statement?  If “yes”, please attach a copy 			
3.	Are MVR’s (Motor Vehicle Reports) ordered and reviewed on all employees (including those employees hired during the policy term) prior to approving the use and operation of the insured’s vehicles, or those employees who will operate their own personal vehicles while performing company duties?  			
4.	How many employees use their personal vehicles for work purposes?         
What percentage of your employees use their personal vehicle in your business?       	
5.	What limit of personal liability insurance do you require employees to carry if they are using their own vehicles for work purposes?       	
6.	Do you rent, hire, or lease vehicles on a short-term basis (6 months or less)? 
If yes, what is your estimated annual cost?        			
7.	Do you have a written procedure of the screening and hiring of drivers?  If “yes”, please attach a copy of your written procedures or provide details below on MVR driving criteria (how many traffic violations, DUI/DWI, Suspended License, etc.      			
8.	Do you have a written policy regarding the use of cell phones while operating vehicles?  If “yes”, please attach a copy 			
9.	Do you have a written Substance Abuse Policy?  If “yes”, please attach a copy 			
10.	Do you have a written policy that applies progressive discipline if a driver begins to develop a pattern of traffic violations or preventable accidents?  If “yes”, please describe.       			
11.	Do you have a scheduled maintenance program for company vehicles?  If “yes”, please describe.       			
12.	Do you have a daily pre-trip inspection procedure for vehicles?  If “yes”, please describe.       			
13.	Do you have an accident reporting kit in every company vehicle?  If “yes”, please describe.       			
14.	Do you allow employees to take company vehicles home?  (if “yes”, complete question 15)			
15.	If you answered “yes” to question 14, are the employees permitted to drive the vehicles during non-work hours?  			

Section 7.  Fraud Warning	
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form.  Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING - It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING  Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
NOTICE TO ALL OTHER STATE APPLICANTS: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.	

Section 8.  Notice to Applicant	
The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated.  Completion of this form does not bind coverage.  Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.  The coverage applied for is solely as stated in the policy and any endorsement thereto, which provides coverage for cleanup costs, bodily injury and property damage liability coverage for claims first made against the insured and reported to the insurer, in writing, during the policy period.  All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and made a part hereof.  The applicant further acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation.	
Applicant Signature	
	
Printed Name	     	
Title	     	
Date