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Professional Pilot Car Insurance Package Application

NOTE: Form is 8 pages long and MUST be completed in its entirety

NOTE: If you prefer to fax your application, please open our printable Pilot Car Insurance application and fax to: (801) 463-6683

2150 South 1300 East
Suite #100
Salt Lake City, UT 84106
Office: (801) 488-0085

Contact:

Jalene Dipietro - jalene@cayias.com

Brianne Bennett - brianne@cayias.com

Charley Cayas - charley@cayias.com

Please allow 48-72 hours to receive a quote (Monday-Friday)

General Information:

Date You Need Coverage By:

Types of Coverage Requested:(Check all that apply) Commercial Auto General Liability Professional Liability Inland Marine

(Commercial Auto coverage can be written on its own)

(MUST have General Liability and Auto Coverage in order to get Professional Liability coverage)

(MUST have General Liability Coverage in order to get Inland Marine coverage)

How did you hear about us?

(If individually owned, please include full name of the business owner and any business name on the company line.)

Business Entity Type: Sole Proprietor Partnership Limited Liability Company/Corporation Privately Held Corporation Division of ____________ Corporation

If a division of a corporation, please fill in the name below

Date Business Started:

What is the best number to contact you? Cell Home

What is the best time to contact you? AM PM

Garaging Address (if different from Mailing Address):

Current Auto Insurance Carrier:

Type of Policy: Personal Commercial

Current General Liability Insurance Carrier

Any claims in the last three years? Yes No

If yes, list type of claim(s) and date(s):

Operations Information:

Types of Services Provided: (Check all that apply and include length of experience for each.) Front Pilot Car Tillering Steerables Route Surveys Traffic Control Night Moves Rear Pilot Car Rigging Hot Shot Height Pole Brokerage

Please include length of experience for the services you have checked above:

*There is no Tillering, Rigging, Steerables, and Hot Shot Services coverage under any circumstances.*

Other Types of Services Provided: (Give Detailed Description, Including Length of Experience)

Do you perform Height Pole work? Yes No

Type of Pole? Homemade Manufactured

Height Pole Guidelines: Height Pole MUST be non-conductive, flexible/frangible, and non-destructive

Height Pole MUST have secure fastening devices to hold pole in place and prevent pole from slipping!

Does your Height Pole meet or exceed the above mentioned guidelines? Yes No

If yes, what percentage of jobs require height pole work?

Specify any training class and when it was taken:

Please describe any experience, training and safeguards used to prevent claims while performing height pole work:

Are you contracted to perform Route Surveys prior to the issuance of the Permit? Yes No

Are you requesting coverage for Route Surveys? Yes No

If yes to the above question, please request and complete the Route Survey Questionnaire page for EVERY driver that will perform Route Surveys.

Do you physically drive the route before producing a paper survey? Yes No

Do you perform Flagging? Yes No

If yes, what percentage of jobs require flagging?

Enter any training class and when it was taken:

Subcontracted/ Brokered Work

A. Do you sub-contract your work with other drivers if you need help? Yes No

Do they provide you with a copy of their Commercial Auto Policy with $1,000,000 CSL and General Liability (GL) policy with matching limits of $1,000,000 Per Occurrence/$2,000,000 Aggregate limit?

(PLEASE NOTE: Do NOT submit application if subs do not carry coverage with matching limits.)

B. If yes, is there a hold harmless agreement in place? (If yes, please provide a copy.) Yes No

C. Are you added as a Certificate Holder or an Additional Insured on the Subcontractors Insurance? Yes No

If no, how do you know their policies are current and active?

D. What protection is put into place to insure policies remain active policies?

E. What are estimated gross annual revenues for subcontracted/brokered work?

Will you be working out of state? Yes No

Will you be traveling outside the US? If yes, please note that no coverage applies to Mexico. Yes No

If traveling to Canada, how frequently?

If traveling to Canada, how far do you travel into Canada?

If traveling to Canada, will you pick up loads while in Canada? Yes No

Please list all forms of communication devices being used during a trip:

Is there a Pre-Trip Coordination and Planning Meeting held prior to load movements? Yes No

Are you provided with copies of permit and routing documents at this Pre-Trip Meeting? Yes No

Do you always get a revised permit in order for movement to continue when any of the following occur?

Bridge too low for load to pass under safely? Yes No

Permit is Incorrect Yes No

Weight of load exceeds bridge capacity? Yes No

Are you using a Post Trip Evaluation and Checklist form? Yes No

Additional General Information Questions:

1. Are any vehicles not solely owned by and registered to the applicant? Yes No

If yes, please provide more detail:

2. Are you requesting coverage for an employee using their own vehicle? Yes No

If yes, provide details:

(Include a copy of the LEGAL lease agreement with your company.)

3. Are any vehicles leased or rented to others? Yes No

If yes, do you have a lease agreement in place? Yes No

(If yes, provide a copy of the legal lease agreement)

4. Do you escort any loads involved in transporting hazardous materials? Yes No

If yes, provide more details:

5. Do you have any signed contracts with companies that you provide services for? Yes No

If yes, please provide a copy of contract(s)!

6. Do you have employees? Yes No

If yes, do you obtain MVR verifications on your employees? Yes No

If yes, how often are they obtained?

7. Are any drivers covered by workers' compensation including, business owner? Yes No

8. Any vehicles to be covered used by family members not listed as a driver on this application under Driver Information? Yes No

If yes, identify who, how often, usage, vehicle number and percentage:

9. Has a driver had his or her certification revoked or suspended? Yes No

If yes, please list driver(s):

10. Is a voice activated recorder used at all times during the entire trip to record all dialog between all parties involved with the movement of the load?

Please answer below: Yes No

If yes, are tapes kept for a minimum of two (2) years? Yes No

If no, will you keep tapes for a minimum of two years in the future? Yes No

11. Have you ever deviated from the permit without prior approval of the Permit Office of the State? Yes No

12. What is the radius of your three longest jobs (in miles):

13. What is the frequency of your pilot car service jobs? Daily Weekly Monthly Other

If other, please provide details:

14. Do you permit non-employee passengers to occupy the vehicle during trips? Yes No

Do you want Equipment Coverage? Yes No

Inland Marine Coverage - Equipment Coverage (Requires General Liability Coverage)

Inland Marine Coverage: $1,000 Limit $2,500 Limit $5,000 Limit

Complete the Vehicle Equipment Schedule Page: (For all attached and unattached equipment and also include the vehicle number that the equipment is in.)

Additional Comments or Information:

List each vehicle that you will be using for your business. If you need to list more vehicles, please request and fill out "Additional Vehicle" page.

Gross Vehicle Weight Rating

Purchase Type New Used

Percentage of Trips Made

Liability Limits: $1,000 Combined Single Limit (CSL); PIP or Medical at $5,000

Types of Coverage Requested

Comprehensive Deductible $250 $500 $1,000

Collision Deductible $250 $500 $1,000

Is there any damage to this vehicle?

If yes, please explain damage

Will this vehicle be for personal use?

If there is a loan against the vehicle, please complete the section below:

Address of Lien Holder

Gross Vehicle Weight Rating

Purchase Type New Used

Percentage of Trips Made

Liability Limits: $1,000 Combined Single Limit (CSL); PIP or Medical at $5,000

Types of Coverage Requested

Comprehensive Deductible $250 $500 $1,000

Collision Deductible $250 $500 $1,000

Is there any damage to this vehicle?

If yes, please describe:

Will this vehicle be used for personal use?

If there is a loan against the vehicle, please complete the section below:

Address of Lien Holder

This information MUST be completed on every driver. If you need to list more drivers, please request and fill out "Additional Drivers" form.

All drivers must meet underwriting guidelines.

Year originally receieved license

Driver's License Number

Moving Violations in last 36 months

Accidents in the last 36 months

Violation description and date

% this person will be using vehicle

Vehicle being driven

Business or Personal?

Types of Services Provided

(Check all that apply and include length of experience for each.)

Front Pilot Car (yes or no, length of experience):

Tillering (yes or no, length of experience):

Steerables (yes or no, length of experience):

Route Surveys (yes or no, length of experience):

Traffic Control (yes or no, length of experience):

Rear Pilot Car (yes or no, length of experience):

Rigging (yes or no, length of experience):

Hot Shot (yes or no, length of experience):

Height Pole (yes or no, length of experience):

Brokerage (yes or no, length of experience):

Other Types of Services Provided:

Pilot/Escort Driver Certification (s): (Include a legible copy of all of your Certification cards)

Certification from what state

Certification Number

Certification from what state

Certification Number

Year originally received license

Driver's License Number

Moving violations in last 36 months

Accidents in last 36 months

Violation description and date

% this person will be using vehicle

Vehicle being driven

Business or Personal?

Types of Services Provided

(Check all that apply and include length of experience for each.)

Front Pilot Car (yes or no, length of experience):

Tillering (yes or no, length of experience):

Steerables (yes or no, length of experience):

Route Surveys (yes or no, length of experience):

Traffic Control (yes or no, length of experience):

Rear Pilot Car (yes or no, length of experience):

Rigging (yes or no, length of experience):

Hot Shot (yes or no, length of experience):

Height Pole (yes or no, length of experience):

Brokerage (yes or no, length of experience):

Other Types of Services Provided:

Pilot/Escort Driver Certification (s): (Include a legible copy of all of your Certification cards)

Certification from what state

Certification Number

Certification from what state

Certification Number

Pilot Car

Health

Commercial Products

Personal Lines

Bonds

Professional Pilot Car Insurance Package Application

General Information:

Operations Information:

Subcontracted/ Brokered Work

Additional General Information Questions:

Vehicle Information

Vehicle #1:

Vehicle #2:

Driver Information

Driver #1

Driver #2

Contact Us Today!
801-488-0085

Resources

Contact Us

Pilot Car

Health

Commercial Products

Personal Lines

Bonds

Professional Pilot Car Insurance Package Application

General Information:

Operations Information:

Subcontracted/ Brokered Work

Additional General Information Questions:

Vehicle Information

Vehicle #1:

Vehicle #2:

Driver Information

Driver #1

Driver #2

Contact Us Today! 801-488-0085

Resources

Contact Us

Contact Us Today!
801-488-0085