SUPPLEMENTAL APPLICATION – TOWING

NEXT: PLEASE FILL OUT THE SUPPLEMENTARY APPLICATION BELOW

Applicant Information:

Company Name:

Business Name (DBA):

Legal Name: *

First

Last

Application ID:

Application completed by:

• Broker:
• Employer:

Please provide (first, last) name: *

First

Last

Date: *

Hours of operation

• 24 hours

a.m.

p.m.

Any driving in excess of 11 hours per shift?

• Yes
• No

Any driving in excess of 60 hours within 7-consecutive days?

• Yes
• No

Total number of vehicle recoveries in the last 12 months by employees:

Any contract towing?

• Yes
• No

If yes – Please explain and provide the list of contracts:

Does the insured perform any of the following?

Vehicle repossession

• Yes
• No

Recovery of vehicles transporting hazardous materials

• Yes
• No

Repelling on hillsides/cliffs/canyons to retrieve vehicles

• Yes
• No

Underwater recovery

• Yes
• No

Low-bed/heavy hauling/transportation of large items such as construction equipment, farm equipment, oversized loads or aircraft?

• Yes
• No

Percentage of towing that are from highways/freeways?

%

What percentage of towing is private property impounding?

%

(Total must equal 100%)

1. What percentage of the insured’s operations involves towing of trucks that are one ton or greater; i.e. buses, RV’s or trailers?

%

2. What percentage involves the towing of vehicles that are less than one ton?

%

Percentage of work sub-contracted out:

%

Are certificates collected annually for sub-contractors?

• Yes
• No

Total number of vehicle recoveries in the last 12 months by Independent contractors:

Please explain the type of work sub-contracted out:

General Classification Evaluation:

1. Maximum Height exposure:

• N/A

Ft.

If applicable - Method of reaching height exposures:

2. Maximum Weight lifted:

• N/A
• If applicable: Manual Lifting

lbs.

Please list the typical types of items lifted:

Employee(s) lifts with assistance:

• .

Please explain:

3) Vehicle exposure:

Total # of Tow Trucks:

Number of employee drivers:

Do employees take the vehicle home overnight?

• Yes
• No

Driving Radius in miles:

mi.

GPS tracking system installed?

• Yes
• No

MVR’s Checked:

• Yes
• No

Company Owned:

• Yes
• No

PUC Filling

• N/A
• Yes

If YES:

MCP Filling

• N/A
• Yes

If YES:

4) Any Out of State, International, or Overnight Travel:

• Yes
• No

If Yes - Please provide the following details below:

Number of employee’s traveling:

Frequency of travel:

Method of transportation:

Location(s)/State(s):

• Alabama
• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• Florida
• Georgia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virginia
• Washington
• West Virginia
• Wisconsin
• Wyoming

Please select all that apply

5) CPR Training provided:

• Yes
• No

If Yes - Number of Employees certified:

Claims Handling:

1) Is there a set procedure for reporting claims?

• Yes
• No

2) Is there a formal written accident investigation report?

• Yes
• No

3) Do you currently participate in an MPN program to control claim costs?

• Yes
• No

Personnel Practices:

1) New-hire orientation program:

• Yes
• No

Is the orientation documented?

• Yes
• No

2) Owner is active in daily operations:

• Yes
• No

3) Employee Handbook:

• Yes
• No

4) Post-accident drug testing:

• Yes
• No

5) Job specific training:

• Yes
• No

6) Performance Appraisals:

• Yes
• No

7) Wellness program in place:

• Yes
• No

8) Are any of the following benefits provided?

Medical:

• Yes
• No

Employer contribution:

%

Percentage of employees enrolled:

%

Retirement:

• Yes
• No

Employer contribution:

%

Percentage of employees enrolled:

%

9) Any other information in regard to employee benefits? If so, please provide those details:

Employer-Employee Relationship:

1) Employee Turnover Rate (Annually):

%

Average Tenure of Employees (in # of years):

2) Number of employees hired:

Full Time (annual)

Payroll Estimate:

Part Time/Seasonal:

Payroll Estimate:

No. of seasonal Employees:

Seasonal Employee Period

From Month:JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

To Month:JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Safety Program/Practices which are implemented and enforced:

1) Fall Protection Plan:

• Yes
• No
• N/A

2) Heat and illness prevention program:

• Yes
• No
• N/A

3) Respiratory program:

• Yes
• No
• N/A

4) Driver safety training plan:

• Yes
• No
• N/A

5) Forklift training & safety plan:

• Yes
• No
• N/A

If Yes – Annual Certification required:

• Yes
• No
• N/A

6) MSDS available for all chemicals/products used:

• Yes
• No
• N/A

7) Written Lockout/Tag out/Block out Procedures:

• Yes
• No
• N/A

8) Hazardous chemicals safety plan:

• Yes
• No
• N/A

9) Confined spaces plan:

• Yes
• No
• N/A

10) Active safety incentive program for all employees:

• Yes
• No
• N/A

11) Are supervisors held accountable for a safe work environment?

• Yes
• No
• N/A

12) Is there a dedicated full time safety manager?

• Yes
• No
• N/A

If Yes – Please provide:

Name *

First

Last

Title

13) Safety meetings are conducted:

• Daily
• Weekly
• Monthly
• Quarterly
• Does not conduct Safety Meetings

Are safety meetings documented?

• Yes
• No

14) Personal Protective equipment provided to all employees:

• Yes
• No

If Yes, please list types below:

15) Employee to Supervisor ratio:

16) What loss prevention recommendations have the insured implemented

• Loss control service has not been performed.

Year implemented:

Please explain...

Machinery and Equipment:

contribution: below: meetings

1) Types of machinery/equipment used:

• N/A

Please list the types of machinery/equipment used:

2) Are all equipment operators certified?

• Yes
• No

3) Is all machinery/equipment properly guarded:

• Yes
• No

4) Age of equipment in years:

• 0-5
• 5-10
• 10-20
• 20+

5) Condition of the equipment:

• Excellent
• Good
• Average
• Poor

6) Who is responsible for maintaining machinery?

• Insured
• Contractor
• Other

If Other:

Is there any other information about your company, operations, or practices you have implemented which could have an impact on mitigating injuries?

Submit

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