Application for Excess Automobile Liability Name of Firm: * First Name Last Name Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: * (###) ### #### Years in business under present ownership: * Business Type: * Corporation Sole Proprietorship Other Other Business Type: Approximate Net Worth: * Area of Operation: Type of Operation: * Radio Dispatch Taxi Taxi - No Radio Limousine Service Exec Car Airport Limousine Handicap Other Method of Operation(s): * Commissioned driver (employee) units Leased Driver Units Driver/Owner Units Is firm certified as an authorized self-insured? * Yes No Will claims be handled by an Adjusting Firm? * Yes No Name of Attorney who will handle Litigations: * If coverage is purchased, you agree to have your attorney furnish quarterly reviews of all quarterly claims that are six months or older and which occurred under the current policy or under previous policies if insured through the same company. First Name Last Name Address of Attorney that will handle Litigations: * Address 1 Address 2 City State/Province Zip/Postal Code Country Are MVR's obtained on all drivers? * Paratransit requires MVR's be ordered every year. However, every 6 months is preferable. Yes No Are prospective drivers required to attend company-sponsored driver training school? * Yes No Is a formal safety program in effect? * Yes No What procedures are followed by your firm when a driver is involved in a chargeable accident or receives a ticket? Do you own a maintenance garage? * Yes No Is there any program of regular vehicle inspection and maintenance other than city or state inspection? * Yes No If cabs are driver owned, is an inspection and maintenance program compulsory? * Yes No Current Insurance Carrier: * Current Insurance Carrier Premium: * Current Insurance Carrier Limits: * Liability Limits & UNinsured/UNDERinsured Motorist Coverage I wish a quote as follows: Please check all that apply: * Liability Limits Retained or SIR Limit I wish to reject uninsured Motorist Coverage if my state permits me to do so. I wish to reject underinsured Motorist Coverage if my state permits me to do so. Quote uninsured Motorist Coverage for minimum limits required in my State of Domicile. Quote underinsured Motorist Coverage for minimum limits required in my State of Domicile. Quote uninsured Motorist Coverage for minimum limits for Policy limits. Quote underinsured Motorist Coverage for minimum limits for Policy limits. Off-Duty Coverage Quote off-duty coverage for lessee or driver-owner. (Maximum limit is $100, 000) LESS the Retained Limit? * Yes No Attachments Agreements It is specifically understood and agreed that this application is made to a Risk Retention Group. A Risk Retention Group may not be subject to all of the Insurance laws and regulations of your state. State Insurance Insolvency Guaranty Funds are not available for a Risk Retention Group. * I agree I do not agree It is further agreed that I (we) hereby make application to become a member of Paratransit Insurance Company, a Mutual Risk Retention Group. * I agree I do not agree Your Name: * Please electronically sign this application. First Name Last Name Email: * A copy of this application will be sent to this address. Thank you!