Tow Truck Supplemental application

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					                                    Berkshire HathawayHomestateCompanies
                                                    Specialty Auto Department

                                               Tow Truck SupplementalApplication

     ApplicantName:
     Address:

     PhoneNumber:

     General Questions:
          1. Descriptionof operations:

          2. YearsExperience:
          3. AnnualGrossReceiptslastyear:                             Estimateof comingyear:
          4. Have you everfiled for bankruptcy?0 Yes           0 No           If yes,when: -
          Explain:
          5. Prior InsuranceCarrier,five previousyears:
                                                                                                              Involved in
                                                                                                           Litigation{Y IN)




     6.                                         or           0
          Hasyour insuranceever lapsed,cancelled, non-renewed? Yes               0 No If yes,explain:




     5.   List the largest cities into or through which vehicles are operated?
               1.                              2.                          3.



     6.
     7.


               0 ICC      MC Docket #                    Base registration state
               0 Oversize / overweight filings
               D Other -describe:
     8,   If you are ICC regulated please attach a copy ofvour Schedul~ for each of the Qastthree years:
               D Attached        D Not Required
          List all kinds and types of cargo hauled: ~




9.
                             or
10. Do you haul anyhazardous extrahazardous              or                       A:
                                              substances materialasdefmedby the EP 0 Yes
                                                                   content:
        If yes,give completelisting, namingmaterial(s)and/orchemical

11. Do you haul anyflammableor explosivematerial?0 Yes               0 No If yes,give completelisting:

12. Do you haul anyliquid material?0 Yes         0 No   If yes,pleasedescribe:


13. Do you haul any heavyand/oroversized          0
                                        equipment? Yes                0 No If yes,give details:

14. Do you haul your own cargo exclusivelyt 0 Yes         0 No   Ifnot, who ownsit:

15. Do you pull doubletrailers?0 Yes 0 ~o        Triple trailers?0 Yes 0 No
16. Do your pull refrigerated                                     and
                             units? 0 Yes I 0 No If yes,describe give detailsof cargohauled?

                             0
17. Do you hire anyequipment? Yes         D iNO If yes, describe annual frequency:




                                           DOT regulations requirements: Yes
19. Have you everbeenin violation of Federal              or           0                      D No    If yes,explain:

19. Have you ever lost or had your authority withdrawn? 0 Yes 0 No
20. Have you been or are you under probation by any regulatory authorities? (ICC, PUC, etc.) 0 Yes
21. Are vehicle inspectionsperfonnedregularly?    0 Yes     0 No       Bywhom?       -

                         for                  0
22. Are vehiclesscheduled regularmaintenance? Yes 0 No Who perfonnsmaintenance?
                       logs
        Are maintenance maintainedfor all vehicles?0 Yes 0 No
                                         company? 0 Yes
23. Do you operateasa subsidiaryof another               0 No If yes,provide nameanddescribe:

24. Do you operateunderany othername? 10Yes             DNo      If yes, please provide details:

                             not        on
25. Do anyvehiclesand/oragents scheduled this policy operateon yourbehalf? 0 Yes                     0 No If yes,provide name(s)
      anddetails:




27. Have you ever changed your operating n$I1e? DYes        D No
28. Are Vehicles stored at a single location? 0 Yes D No
         If yes, total maximum value of all vehicles at anyone time:


Driver Information:
                                 0
1. Are all drivers your employees? Yes                  explain:
                                              0 No If DO,

2.                                                              D
     Are all drivers listed on the acordapplicationfor insurance? Yes D No
3.   Are all of your employees   coveredby Workers' Compensation?  DYes D No
4.   Do you agreeto promptly reportall newly hired drivers?D Yes D No
5.   Do you orderMVR' s on all driversprior to hiring? DYes D No
6.   Minimum yearsdriving experience     required:
7.   How aredriverspaid: D Hourly D Trip D Mileage D Other:
8.   Drivers maximumdriving hours: Daily I                           Weekly
                                                                 2
9. During the last 12months,how manydriverswere: Hired.                    Fired                Quit
10. Numberof driversemployedby you:




11. Are drivers allowedto takevehicleshome: 0 Yes        0 No

Towina/GaraaeOoerations:
 .Number of units thatareflatbed tow trucksie. rollbacks                 OR on-hook wreckers              ?
  Canmore than onevehiclebe towed at onetime?

2. Types of autostowed (Circle all that applyandgive percentagesbelow):
   PPT's / Light trucks / Heavytrucks / Tractors / Motorhomes / Mobile Homes
   Other

  % of PPT/Light! Med trucks towed                                              motorhomes
                                                      VS % heavy trucks,tractors,        etc

3. Any recoveryoperations?      Yes / No                              operations? Yes / No
                                                       Any repossession

                            provided? Yes / No (If yes -Explain)
4. Any roadsiderepairservices



5. Any repairsshop operations?Yes / No         (If yes -Explain)


6. Operate an impound or storage lot? Yes I No
   Standard I nonstandard open lot protection? ~
   Lot Protection: fenced -chain link? Y e~I No                 Lighted? Yes /No
   Average number of cars in lot?             !                 Maximum numberof carsin lot?
   Average length of storage?

   Any Salvageyard operations?Yes / No                     UsedCarssalesoperations?Yes /No
  Auto partssales? Yes / No

                  on
8. Is the business rotationwith the public entity or 24 hour? Yes /No
                     with AAA?
    Are theyassociated               Yes fiNo
   Other customers:                        I


9. MaximumRadiusOperated?-                                      Any interstateTowing? Yes /No
   If yes-please explainin detail-whereand how often.



                                                         above?
10. Any othercar hauling lotheroperations not contemplated




  Signature Producer
           of                                                                                  of
                                                                                      Signature Insured
                                                                3

				
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posted:10/17/2012
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