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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:

Types of Coverage Requested:(Check all that apply)

(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)

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

Business Entity Type:
What is the best number to contact you?
What is the best time to contact you?
Type of Policy:
Any claims in the last three years?

Operations Information:

Types of Services Provided: (Check all that apply and include length of experience for each.)

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

Do you perform Height Pole work?
Type of Pole?

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?
Are you contracted to perform Route Surveys prior to the issuance of the Permit?
Are you requesting coverage for Route Surveys?

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?
Do you perform Flagging?

Subcontracted/ Brokered Work

A. Do you sub-contract your work with other drivers if you need help?

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?

If yes:

(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.)
C. Are you added as a Certificate Holder or an Additional Insured on the Subcontractors Insurance?
Will you be working out of state?
Will you be traveling outside the US? If yes, please note that no coverage applies to Mexico.
If traveling to Canada, will you pick up loads while in Canada?
Is there a Pre-Trip Coordination and Planning Meeting held prior to load movements?
Are you provided with copies of permit and routing documents at this Pre-Trip Meeting?

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

Road Detour
Bridge too low for load to pass under safely?
Permit is Incorrect
Weight of load exceeds bridge capacity?
Are you using a Post Trip Evaluation and Checklist form?

Additional General Information Questions:

1. Are any vehicles not solely owned by and registered to the applicant?
2. Are you requesting coverage for an employee using their own vehicle?

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

3. Are any vehicles leased or rented to others?
If yes, do you have a lease agreement in place?

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

4. Do you escort any loads involved in transporting hazardous materials?
5. Do you have any signed contracts with companies that you provide services for?

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

6. Do you have employees?
If yes, do you obtain MVR verifications on your employees?
7. Are any drivers covered by workers' compensation including, business owner?
8. Any vehicles to be covered used by family members not listed as a driver on this application under Driver Information?
9. Has a driver had his or her certification revoked or suspended?

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:
If yes, are tapes kept for a minimum of two (2) years?
If no, will you keep tapes for a minimum of two years in the future?
11. Have you ever deviated from the permit without prior approval of the Permit Office of the State?
13. What is the frequency of your pilot car service jobs?
14. Do you permit non-employee passengers to occupy the vehicle during trips?
Do you want Equipment Coverage?

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

Inland Marine Coverage:

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

Vehicle 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.

Vehicle #1:

Purchase Type

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

Comprehensive Deductible
Collision Deductible

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

Vehicle #2:

Purchase Type

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

Comprehensive Deductible
Collision Deductible

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

Driver Information

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.

Driver #1

Sex

Types of Services Provided

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

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

Driver #2

Sex

Types of Services Provided

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

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

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801-488-0085

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2725 E Parleys Way Ste 170
Salt lake city, UT 84109

Ph: 801-488-0085 | charley@cayias.com
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