Does Your Business
Operate More Than 10 Vehicles? No
Yes
( If "Yes" please indicate total
number of vehicles
and we will email you a supplemental vehicle schedule
)
Coverage Limits:
Vehicle
Number
BI/PD
UMBI/PD
PIP/MED
COMP
Ded
COLL
Ded
Towing
Rental Car
Vehicle 1
Vehicle 2
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 3
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 4
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 5
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 6
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 7
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 8
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 9
same as vehicle 1
same as vehicle 1
same as vehicle 1
Vehicle 10
same as vehicle 1
same as vehicle 1
same as vehicle 1
Commerical
Vehicle
Claim/Loss
History Information:
*Has
your business had any losses or claims filed
for a
commerical automobile/vehicle loss in the last
five years? YesNo
If "Yes" Please Provide
Full Details with name of diver involved /
amount paid by your insurer / policy # /
date of loss / nature of claim (
accident/theft/comp) / full details
regarding bodily injury sustained with
names of injured parties.
Did
any loss involve one of the drivers listed
above ?
Yes
No
( If "Yes" Please provide driver number
)
If
that driver was issued a traffic ticket
violation please indicate nature of
violation:
If
your business has had multiple
claims/losses in the past five years
please indicate this in the history
comment section above and our staff will
contract you for additional details.
General Underwriting Information:
Pre-selected (Default ) answers have been selected by us to
aid you in completion of this form; please make any
necessary corrections.
Please review each check box below to assure that each
question is correctly answered; then change the checked box
to the most appropriately response that applies to your
request for a rate quote. Any incorrect information obtained
from you may void the quick quote rate you receive.
1.
Is coverage requested for all of
business' commercially owned and
operated vehicles?
YesNo
2.
Are any state or federal flings
required ?YesNo
3.
Are there any Additional Insured's
that need to listed on you policy as a
named insured for coverage ?YesNo
4.
Does your business need to provide any
other entity or person with a Waiver
of Subrogation to restrict your firm
or insurance carriers right of
subrogating
against them in the event
of another parties negligence ?YesNo
5.
Does your business own/lease/rent any
trailers ?YesNo
6.
Are any of your firm's business
vehicles used by family members who
are not actively employed in your
business ?YesNo
7.
Are any of your business vehicles used
to transport people or property for
hire?YesNo
8.
Is the primary purpose of any vehicle
listed above to transport person;
other than your employees ?YesNo
9.
Does you business require or allow any
employees to use their personally
owned/ leased /or hired vehicles
for business purposes?
YesNo
If " Yes " we recommend adding a
hired/non-owned endorsement to your
commercial auto liability coverage.
10. Is your firm a subsidiary
of another entity? YesNo
11. Is a formal written safety program in
operation?
YesNo
12. Does your firms have any
subsidiaries ? YesNo
13. Any exposure to flammables,
explosives , chemicals,
or other hazardous materials
?
YesNo
14. Any catastrophe exposures ?
Yes
No
15. Are you currently insured for other
types of coverage with any of the insurance
carriers we are offering you coverage
with ? YesNo
16. During the last five years has any
applicant been indicted for or
convicted of an degree of the crime of
fraud, bribery, arson or any other
arson-related crime in
connection with
this or any other property? YesNo
17.
Any bankruptcies. tax or credit liens
against the applicant in the past five
(5) years?
Yes
No
18.
Has any of your business
interest been placed in a trust? Yes
No
( If "Yes" Name Trust In Comments
Below )
If you answered " Yes
" to 1 through 18 above please indicate
question # and briefly explain
below:
Comments/Remarks:
Submission of quote request form
to Hemphill Insurance Agency does not constitute
a binding confirmation of new or revised
insurance coverage. To confirm binding or
current policy revisions you must receive a
written confirmation for any new or change
in coverage from our agency staff.
Auto insurance pays for damages, injuries, and
other losses that are detailed in your policy. Depending on the type of
coverage, auto insurance can either pay for your damages or another driver’s
damages, or a passengers damages.
The most common types of auto insurance are:
LIABILITY pays for damage caused by you to another person or
another person's vehicle or other property as a result of an automobile
accident. Types of liability coverage include:
Bodily
Injury (BI) If you injure someone in an auto accident for which
you are legally to blame, this coverage will pay claims for injury or
death against you and the cost of legal defense.
Please keep in mind that you are responsible for any amount of a
covered loss that exceeds the amount of insurance coverage you purchase;
therefore we highly recommend you consider securing higher limits of
bodily insured auto liability coverage to protect your personal assets in
the event of a large liability settlement or a count renders a judgment
for a dollar amount that exceeds your policy limits. We would highly
recommend you request a quote for a Personal Umbrella Liability
Policy as recent court judgments to claimants for wrongful death , pain
& suffering due to injuries , medical expenses , and/or loss of income due
to a negligence of another party have been substantial.
Property damage (PD) pays for damage that you cause to someone
else's vehicle or property for which you are legally liable. This does not
cover your car or property.
Please keep in mind that you are responsible for any amount of a
covered loss that exceeds the amount of insurance coverage you purchase;
therefore we highly recommend you consider securing higher limits of
property coverage to protect your personal assets in the event of a large
liability settlement or a court renders a judgment for a dollar amount
that exceeds your auto property damage policy limits due damages you cause
to someone else's property. Accidents involving
multiple automobiles, high valued automobiles, or commerical vehicles may
result in substantial losses that exceed coverage limits available under a
standard Texas auto policy so we would highly recommend you request a
quote for a personal Umbrella Liability Coverage.
Medical payments pays for medical, hospital or funeral expenses
for you and others injured or killed while riding in your car, regardless
of fault. It also covers you and family members if struck by a car as a
pedestrian or if riding in another car.
PHYSICAL DAMAGE pays for a loss resulting from damage to your
vehicle or a vehicle operated by you. Physical damage also provides coverage
if your vehicle is stolen. Types of physical damage coverage include:
Collision pays for damage to your car from an accident
regardless of fault. It usually includes a deductible and the insurance
company pays the rest. Selecting a larger deductible can lower your
collision premium.
Other
Than Collision (Comprehensive) pays for damage to your car caused
by most anything other than a collision. Glass breakage, theft, fire,
explosion, impact with an animal, vandalism and flood are some of these
hazards. This coverage is also available with deductibles to lower your
premium.
OTHER COVERAGE Other types of auto coverage include:
Uninsured Motorists (UM) Unfortunately, not everyone purchases
auto insurance. If you or your passengers are injured by someone who does
not carry auto insurance, UM coverage will pay for injuries up to your
policy limits. This includes medical expenses, loss of wages, and related
expenses. UM coverage also applies if you are a victim of a hit-and-run
driver.
Underinsured Motorists (UIM) Just as some drivers don't carry any
auto insurance, other's don't carry enough to pay for damages from their
accidents. UIM coverage pays for death and injury expenses to you or
occupants of your car when the other person's insurance is inadequate.
Personal Injury Protection (PIP)) Coverage pays for medical
expenses and 80% of lost income, regardless of who is at fault in the
accident. It also pays for assistance with personal services you are
unable to perform because of an auto accident. You, your family members,
and your injured passengers are covered under PIP. Insurance; insurance companies
must offer to sell you PIP coverage (and Uninsured Motorist Coverage)
along with your liability coverage. If you decide not to purchase PIP, you
must reject it in writing. PIP coverage is available at limits of $2500
and up.
Rental Reimbursement pays for the cost to rent an
automobile up to the daily and total maximum amount of coverage you
purchase ;up to your available policy limits; while your vehicle
is being repaired or replaced should a total loss occur from damage or
theft.
Towing pays for the cost have your vehicle towed to a
