[[[["field8","equal_to","Yes"]],[["show_fields","field9"]],"and"],[[["field11","equal_to","Yes"]],[["show_fields","field12"]],"and"],[[["field13","equal_to","Yes"]],[["show_fields","field14,field15"]],"and"]]
1 Step 1

Residential Care Facility Vehicle Application

(note: All questions must be answered or application will be returned)

NameUse your name from the previous Application
Automobile Liability Limits and Exposures
1. Please select the requested automobile coverage:
2. Please select the requested limits:(check all that apply)
3. Please provide the total number of employees & contractors:
4. Do you have any owned autos (including vehicles in the owner’s name that are used for business purposes)?
5. Do you contract with a third party entity to provide transportation services?
If yes, please provide a copy of the contract.You may use this file uploader to provide a copy of the contract.
Upload
Automobile Liability Underwriting Information
1. Do employees or independent contractors use their vehicles on your behalf?
If yes, do you verify their insurance coverage?
2. Do employees or independent contractors use their own vehicle to transport clients/residents?
If yes, do employees or independent contractors transport non-ambulatory clients?
If yes, are all vehicles equipped with wheelchair locks/lifts?
3. Do employees or independent contractors operate ANY vehicles that are owned by clients/residents?
4. Are certificate/proof of insurance obtained at time of hire and annually thereafter?
5. What limits of insurance does the applicant require all employees and independent contractors to maintain?
6. Does the applicant obtain MVR’s prior to hire and annually thereafter for all employees and contractors?
7. Does the applicant allow drivers who have been convicted of a DUI, DWI, or Vehicular Manslaughter to drive on their behalf?
8. Are any drivers under the age of 21 or over the age of 70 allowed to drive?

 

 

Applicant's Signature
Date

 

 

 

California License Number 0E24825

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