Non-Emergency Medical Transportation Please fill out the form below to download the application and vehicle sheet. Send it back to us and and we’ll contact you with more information. Agency/Producer InformationAgency Agency's Phone NumberProducer Producer's Phone NumberBasic InformationCompany Name(Required) FEIN or SSN(Required) Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Website (if applicable) Detailed description of insured's operations(Required)What is your radius of operation (in miles)?(Required) What was the fleet's total mileage last year?(Required) How many years have you been in business?(Required) If you are a new venture, have you ever driven for, or have you ever been associated with another passenger transportation company?(Required) Yes No Name of the associated passenger transportation company?(Required) Dates employeed/associated(Required) Address of previously associated passenger transportation company(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your business required to submit any filing?(Required) Yes No ICC/PUC docket #(Required) What percentage of business is dispatched?(Required)What percentage of business is not NEMT?(Required)Please provide names of organizations with which you have current contracts to provide transportation services:(Required)Do you ever transport unscheduled passengers?(Required) Yes No Please explain the transportation of unscheduled passengers(Required) Please indicate the percentage of trips that fall into the following categories. (Rows should equal 100%)Wheelchair(Required)Stretcher(Required)Passenger(Required)HiddenPercentage Calculation 1The total entered is less than 100%The total entered is greater than 100%Curb-to-Curb(Required)Door-to-door(Required)Door-through-door(Required)HiddenPercentage Calculation 2The total entered is less than 100%The total entered is greater than 100%Prescheduled(Required)On-Demand(Required)Emergency(Required)HiddenPercentage Calculation 3The total entered is less than 100%The total entered is greater than 100%Vehicle InformationHow many vehicles do you own?(Required)Are all the vehicles both titled and registered to the named insured?(Required) Yes No Are the vehicles titled/licensed in the state in which they operate?(Required) Yes No Do you subcontract work to others?(Required) Yes No Do you have a written vehicle maintenance program?(Required) Yes No Do you accept fares utilizing any type of passenger-hailing mobile applications (e.g. Uber, Lyft, Hailo)(Required) Yes No Do you regularly perform "pre" and "post" trip vehicle inspections?(Required) Yes No Special EquipmentDo the insured vehicles have any of the following equipment? Lift-out/Pull-out Ramps(Required) Yes No Number of vehicles that have lift-out/pull-out ramps(Required) Mechanical Lifts(Required) Yes No Number of vehicles that have mechanical lifts(Required) Wheelchair Passenger/Patient Safety Restraint System(Required) Yes No Number of vehicles that have wheelchair passenger/ patient safety restraint systems(Required) Automatic Breaking Sensor, or any other type of ACTIVE Accident-Avoidance Technology(Required) Yes No Number of vehicles with ACTIVE Accident Avoidance Technology(Required) Driver's Seat Vibration or Audible Alarm, or any other type of PASSIVE Accident-Avoidance Technology(Required) Yes No Number of vehicles with PASSIVE Accident-Avoidance Technology(Required) GPS(Required) Yes No Number of vehicles with GPS(Required) In-Vehicle Camera(Required) Yes No Number of vehicles with In-Vehicle Camera(Required) Driver InformationCurrent Number of Drivers(Required)Minimum Age Requirement for Drivers(Required) Do you review MVRs before hiring?(Required) Yes No Do you have a written driver training program?(Required) Yes No Do drivers complete the following (check all that apply)(Required) Written Application Defensive Driver Training Emergency Vehicle Evacuation Training Passenger Assistance Training Primary First Aid Wheelchair & Stretcher Securement Training How often do you hold safety meetings?(Required) Never Semi-Annually Annually Quarterly Monthly Do you provide Workers Compensation Coverage for your drivers?(Required) Yes No Do you utilize volunteer drivers?(Required) Yes No Do you require a 10 panel drug test?(Required) Yes No Do the drivers take any vehicles home?(Required) Yes No Are any of the vehicles used by family members?(Required) Yes No Are your drivers employees of your company or independent operators?(Required) Employees Independent Operators Have you or an employee ever been accused of sexual assault or molestation?(Required) Yes No Please explain more about you or an employee having been accused of sexual assault or molestation(Required) The completion of this supplemental application creates no express or implied obligation on the part of the company or its manager to offer a quotation or provide insuranceSignature of Insured(Required)Title(Required) Date MM slash DD slash YYYY Complete Submission RequirementsMinimum of 5 years of hard copy loss runs valued within the last 60 days No Current drivers list and MVRs generated within the last 60 days Yes Δ