(952) 746-5770
7600 Parklawn Avenue, Ste 350, Edina, Minnesota 55435

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Non-Owned Auto Coverage Supplement

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Supplemental Information

Name of Business:*

Business Contact:*

Contact Phone:*

Contact Email:*

Is Non-Ownership Liability Coverage being required by contract?*

Yes No

Is Non-Ownership Liability Coverage being required by umbrella carrier?*

Yes No

Is Non-Ownership Liability Coverage being required by other?*

Yes No

If other, please explain:

Total number of employees:*

Total number of non-owned autos used in your business:*

Will non-owned autos other than private passenger types, pickups or vans be used?*

Yes No

If yes, how often and why?

Are passengers transported?*

Yes No

Are non-owned autos likely to be operated beyond 200 miles?*

Yes No

If yes, how often and why?

If this is a social service operation, indicate the total number of volunteers furnishing autos for your operation:

Maximum number of volunteers at one time:

How often are non-owned autos used in your business?

Estimate the number of hours non-owned autos are used per month:

Do your employees lease autos on your behalf?*

Yes No

If yes, under whose name are the autos leased?

Do you report employee mileage reimbursements for tax purposes?

Yes No

If yes, how many miles were reported last year?

What is the estimated annual mileage for use of all non-owned autos (regardless of tax reimbursement status)

Do you require employees to have their own insurance?

Yes No

If yes, what are the minimum limits required?

Do you require proof of insurance?

Yes No

Will you use non-owned autos other than those owned by your employees?*

Yes No

If yes, whose autos will you be using?

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:

Complete if Non-Owned Coverage is Requested

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