Non-Emergency Medical and Handicapped Transportation Supplemental Application

Business Information

Name of Business:*

Business Contact Name:*

Contact Email:*

Contact Phone:*

Contact Fax:

Is Non-Emergency transportation your only business?*

Yes No

Number of years company in business:*

Number of years under current ownership:*

Number of years current management in place:*

Operation Type:*

For Hire Non-Profit Profit

How are fares charged?*

If answer to previous question is 'Other' please explain:

Percent of passengers who are handicapped - Wheelchair:*

Percent of passengers who are handicapped - Gurney:*

Are you a member of the Community Transportation Association of America?*

Yes No

Operations

Hours of Operation:*

Cities Operated In:*

Dispatching how far in advance?*

Driver Hiring Criteria - Age:*

Driver Hiring Criteria - Experience:*

Driver Hiring Criteria - MVR:*

Driver Turnover - # hired 12 months:*

Driver Turnover - Average # driver positions 12 months:*

Pre-Employment and Random Drug Testing Program in place?*

Yes No

Frequency of Written Inspections - Vehicles:*

Frequency of Written Inspections - Wheelchair Lifts:*

Documented Safety Program? (If yes, please attach or FAX a copy.)*

Yes No

Are your drivers all trained in PASS?*

Yes No

If yes, date of last training:

Driver Disciplinary/Incentive Program? (If yes, please attach a copy.)*

Yes No

Describe Drvier Training - First Aid/CPR:*

Describe Drvier Training - ADA:*

Describe Drvier Training - Operation of Lift:*

Describe Drvier Training - Wheelchair Securement:*

Describe Drvier Training - Passenger Assistance:*

Describe Drvier Training - Defensive Driving:*

Vehicle Schedule

Year:*

Make:*

Model:*

VIN:*

Lift?*

Yes No

Sirens/Emergency Lights:*

Yes No

Number of Wheelchair Spaces:*

Number of Other Seats:*

Manufacturer's Seating Capacity:*

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to furnish a quote based on the information you provide. The more complete your information, the more accurate your quote will be.

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Non-Emergency Medical and Handicapped Transportation Supplemental Application

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