BERKSHIRE HATHAWAY HOMESTATE COMPANIES
PUBLIC AUTO SUPPLEMENTAL APPLICATION
SECTION 1 - APPLICANT INFORMATION
Policy Period Requested: From __/__/____ To __/__/____
Applicant Info
Business Trade Name:_______________________
Mailing Address:____________________________
City:____________________________________
State:_______ Zip:__________________________
Garaging Address: __________________________
Phone:____________________________________
Internet Address:____________________________
U.S. DOT #:_________________
M.C. #:_____________________
Agency Info
Agency Name:_____________________________
Mailing Address:___________________________
City:_____________________________________
State:________Zip:______________
Phone:____________________________________
Contact Person:_____________________________
SECTION 2 - SUMMARY OF OPERATIONS
1. Please provide a brief description of operations:
2. How many years has this company been in business?______
3. If less than 2 years, what prior public livery experience does the insured have? ___________________________
4. What % of trips are: 0–100 miles ____% 101–300 ____% 301-500 ____% 501–1000 ____% 1000+____%
5. Please identify Metropolitan Area Traveled Through or Into (if not listed fill in at end):
Atlanta
Cleveland
Jacksonville
Milwaukee
Philadelphia
Baltimore/DC
Dallas/Ft Worth
Kansas City
Mpls/St. Paul
Phoenix
Boston
Denver
Little Rock
Nashville
Pittsburgh
Buffalo
Detroit
Los Angeles
New Orleans
Portland
Charlotte
Hartford
Louisville
New York City
Richmond
Chicago
Houston
Memphis
Oklahoma City
St. Louis
Cincinnati
Indianapolis
Miami
Omaha
Salt Lake City
6. What percentage of operations are (fill in all that apply):
Operation
%
Operation
Special Occasion Limousine
School Buses
Airport Shuttle (Limo or Bus)
Church / Boy Scout Buses
Executive Transport
Nursing Care Facility
Hotel Shuttle
Assisted Living Facility
Parking Lot Shuttle
Retirement Community
Employee/Company Shuttle
Sightseeing (Local) Tours
Van Pool
Railroad Labor Shuttle
Farm Labor Transport
Guides and Outfitters
Social Services (specify)
Casino Buses
%
Operation
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%
Taxis
Ambulance Service
Non-Emergency Medical
Charter Buses
Athletic Team Buses - Pro
Athletic Team Buses Amateur
Entertainer Buses
City Transit Buses
Intercity Buses
7. Is your business currently in bankruptcy or filed for bankruptcy in the last 5 years?
8. Is your business for-hire / for-profit?
9. Do you ever transport unscheduled passengers?
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San Diego
San Francisco
Seattle
Tulsa
Yes
Yes
Yes
No
No
No
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10. Exposure History
Year
Projected Coming Year
Most Recent Year
Prior Year
Gross Receipts
11. Insurance History & Loss Experience
Year
Carrier
# of Vehicles
Premium
Mileage
# of Claims
Total Incurred
Number of Vehicles
Liability Deductible/SIR
(Please provide hard copy, currently valued Company loss runs for the current year and 4 prior policy years.)
SECTION 3 – FILING INFORMATION & OPERATING HISTORY
1.Filings Required:
Filing Type Required
Motor Carrier # Applicant’s Name & Address As It Appears on Permit
Liability BMC91x
Liability – Form E _____ State
If an MCS-90 is issued, BHHC will issue with the required limits as posted on the FMSCA website. Please note 35
days notice of cancellation is mandatory on all policies that have an MCS-90 or other filings. BHHC requires all
units to be scheduled when an MCS-90 or other filings are issued.
2. Do you operate, or have you ever operated, under a different name (if “Yes” provide names below)?
3. Do you appoint agents on your behalf? (if “Yes” provide detail below)
N/A
4. Do you operate as a subsidiary of another company? (if “Yes” list company name below)
5. Do you share common ownership with any other businesses? (if “Yes” list business names below)
6. Do you lease your authority? (if “Yes” provide details below)
N/A
7. Have you ever lost or had your authority withdrawn? (if “Yes” provide details below)
N/A
8. Have you been or are you under probation by any regulatory authorities (ICC, PUC, etc.)?
N/A
9. Do you use “Independent Contractors” or “Owner-Operators” as drivers?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
If answered “Yes” to any questions above, please provide details:
SECTION 4 – LEASED OR HIRED EXPOSURE
If you do not lease or hire vehicles and drivers to or from others, check box to the right and skip the rest of this section.
1. Are all vehicles operated under the applicant’s authority scheduled on the application?
2. Are all owned vehicles scheduled on this application?
3. Are all the scheduled vehicles on this application owned by you?
If you answered “No” to any of questions 1-3 above, please provide details:
Yes
Yes
Yes
No
No
No
4. Do you ever hire or lease vehicles with a seating capacity of 16 or more passengers?
Yes
5. Do you lease or hire vehicles from others?
Yes
No
If yes, is it:
Permanently Leased
Trip Leased (Please check both if applicable)
6. For Permanently Leased Vehicles (if checked above in Question 5):
a. Are the permanently leased vehicles scheduled on this application?
Yes
No
If “No”, what is the estimated cost of hire?_____________
b. If permanently leased, are autos hired with drivers?
Yes
No
c. Do these vehicles operate under your authority (if applicable)?
Yes
No
No
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7. For non-permanently leased or hired vehicles (if checked above in Question 5):
a. Are they required to provide primary insurance?
b. Do you require Certificates of Insurance?
c. Are you named as an additional insured?
d. What is the minimum liability limit required? $_______________
e. What is the estimated annual cost of hire: Current Year: $___________
8. Do you lease vehicles to other public livery businesses? Yes
No
a. If yes, who must provide primary insurance?
You
Other
b. Will vehicle be leased:
With driver
Yes
Yes
Yes
No
No
No
Prior Year: $____________
Without Driver
SECTION 5 – DRIVER INFORMATION
1. Are all drivers your employees?
Yes
No Are all listed on your accord application?
Yes
No
2. Are all your employees covered by Worker’s Compensation?
Yes
No
3. Are drivers ever allowed to take vehicles home at night?
Yes
No
4. Do any drivers carry weapons?
Yes
No
5. Are family members or other relatives (that are not employees) allowed to drive vehicles?
Yes
No
4. Do you have a written personal use policy in place?
Yes
No
5. Do you agree to promptly report all newly hired drivers?
Yes
No
6. Do you order MVR’s on all drivers prior to hiring?
Yes
No
7. Do all drivers have necessary license endorsements (ex. School Bus drivers)?
Yes
No
8. Minimum years driving experience required? ______
9. Age of Drivers: What is the minimum acceptable age of any driver: ______
10. How are drivers paid:
Salaried
Hourly
Trip
Mileage
Revenue
Other ________________
11. During the last 12 months, how many drivers were: Hired______ Fired/Quit______
SECTION 6 – FLEET INFORMATION, SAFETY & VEHICLE MAINTENANCE
1. Of the vehicles to be scheduled on this policy, how many are:
Owned by Applicant
Owned by Leasing Company (long term lease without a driver)
Owned by Owner Operator (leased with driver)
Owned by Employee of named insured (officer)
Other (specify)
2. Are any vehicles wheelchair lift equipped?
Yes
No
3. Are any vehicles equipped with a fare box or meter?
Yes
No
4. Are your vehicles equipped with Telephones (or Drivers carry cell phones)?
Yes
No
5. Are your vehicles equipped with GPS Tracking?
Yes
No
6. Are your vehicles equipped with Drive Cam or other Cameras?
Yes
No
7. Are your vehicles equipped with Emergency Equipment (fire extinguishers, first aid kit, etc..)?
Yes
No
8. Are school buses equipped with flashing lights and automatic stop signs?
N/A
Yes
No
9. Is there a formal, written safety program in place?
Yes
No
10. Name, Title and Phone number of person responsible for safety:
Name:_____________________ Title: __________________________ Phone number: _________________
11. Are you operating your vehicles with speed governors? Yes
No At what speed are they set? ________
12. Are vehicle inspections performed regularly?
Yes
No How often? _________ By whom? _________
13. Are vehicles scheduled for regular maintenance?
Yes
No How often? ________________________
By whom? ___________________ Are maintenance logs maintained for all vehicles?
Yes
No
14. Do any vehicles provide open-air seating?
Yes
No
15. Do you agree to promptly report all new vehicles?
Yes
No
16. What security is provided for vehicles? (Check all that apply)
At Locations Fenced Lot
Security Guards
In a Locked Building
Kingpin Locks
Building Theft Alarm
Vehicle Theft Alarm Person in the Vehicle
In transit
Lojack or other GPS device
Armed Guard in the Vehicle
Vehicle Theft Alarm
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Other, please describe _______________________________________________
SECTION 8 – PUBLIC LIVERY GENERAL LIABILITY
If you are not requesting General Liability Coverage, please check box to the right and proceed to next section:
1. Do you have any physical business locations?
Yes
Location Address
Description
Do you store flammable or toxic substances?
Yes
No If yes complete the following
Area in
Number of
Non-Driver Payroll
Square Feet
Non-Driver
Employees
No
2. Do you have exposure to any of the following exposures:
Do you repair or service vehicles of others?
Do your drivers carry firearms?
Do you specialize in transport of High Profile individuals (athletes, entertainers, celebrities)?
Exposure to Asbestos or other Hazardous Materials?
Operate a towing service?
Own or operate an underground fuel tank?
Use an aircraft?
Arrange tours or other non-vehicle operations?
Do you serve or provide Alcohol?
Do you engage in any other operations beside operation of public vehicles, please describe:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
SECTION 7 – ADDITIONAL INSUREDS AND CERTIFICATES OF INSURANCE
Does the Applicant require any non-standard additional insured endorsements (non-ISO) or certificates (non-ACORD) for
specific additional insureds (common examples are airports or large corporate customers)?
Yes
No
If the answer to the above question in is “Yes”, please attach copies of needed endorsements and certificates (Auto
and GL if requested). If not approved ahead of time, we cannot guarantee we will be willing to provide them after
binding.
SECTION 9 – WORKERS’ COMPENSATION
If you are not requesting Workers’ Compensation Coverage, please check box to the right and proceed to next section:
1. What states serve as business offices? _____________________________________________________________
2. Do all drivers out of these business offices reside in the same state?
Yes
No
If not, state any exceptions:________________________________________________________
3. Number of company drivers with the insured at least 12 months: ____________
4. Number of Non-Union drivers: ________ Union: _______
5. Do the drivers load/unload bags and luggage?
Yes
No
If yes, please provide details:_______________________________________________________________
8. Any overnight travel?
Yes
No If yes, please explain: ___________________________________
9. Indicate the amount of travel between midnight and 5 AM as a % of travel? _____________
10. Does the company have formal methods for the training of drivers in the properties of their passengers and
emergency procedures?
Yes
No Explain: _______________________________________________
12. Does the pre-employment process include drug, alcohol, vision & strength testing?
Yes
No
13. Does the insured have a formal Return to Modified Work or Light Duty program?
Yes
No
What % of employees have light duty available to them? _____% Please define: _____________________
14. Does the company utilize specific medical clinic for work related injuries?
Yes
No
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SECTION 10 – MINIMUM INFORMATION REQUIRED TO FURNISH QUOTE
A. ACORD 125, ACORD 127, and ACORD 129 Application.
B. Currently valued insurance company loss runs for the present and prior 2 years. For risks with 10+ units, loss
runs are required for present and prior 4 years.
C. Complete driver list, both company and owner-operator, showing full name, date of birth, drivers license number,
and date of hire.
D. Complete list of all equipment – including complete serial number, gross vehicle weight and stated value (if
physical damage coverage is requested), including owned or leased and owner-operated.
E. IFTA Schedule B Fuel Tax Report for the prior 4 quarters for any operation subject to Fuel Tax reporting
requirements.
F. Provide copies of any non-standard additional insured endorsements or certificates of insurance required.
G. Current annual financial statement – including profit & loss, balance sheet & cash flow. (for 10 + units only)
SECTION 11 – DISCLOSURE AND SIGNATURES
The company is relying upon the statements and representations made by the applicant or the agent in this application in determining
whether to issue a policy of insurance with the coverages requested by the applicant. The company considers these statements and
representations to be material to the risk or hazard to be assumed by the company. It is understood and agreed that this application,
and the statements and representations made herein, shall be and hereby are incorporated into and made a part of the policy issued to
the applicant by the company. If either the applicant or agent fails to disclose materials factors or provides false information, it may
result in the company denying coverage or rescinding the policy.
Any person who knowingly and with intent to defraud any insurance company or another 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 will subject the person to criminal and (NY:
Substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; In DC, LA, ME, TN, VA, and WA, insurance
benefits may also be denied)
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the
answers to questions on this application. He/She certifies that the answers are true, correct, and complete to the best of his/her
knowledge.
_______________________________
Producer Signature
________________________________
Applicant Signature
_______________________________
Today’s Date
________________________________
Today’s Date
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