NEMT Insurance Application Checklist: What to Gather Before You Ask for Quotes

An agent can only shop your company with the facts you hand over. A missing VIN, an old driving record, or a loss run that never arrived holds up every quote at once. This checklist puts what an insurance application asks for, and what your brokers will look for on the policy, into one package you fill in once and send to every agent. For the limits each state and broker sets, see NEMT insurance requirements. If an insurer has already turned you down, start with NEMT insurance denied.

How to use this template

1. Start with your contracts. Get the insurance section of every broker, health plan, facility, and public contract you hold or plan to sign, and fill in Part 6 from them. Your policy has to meet the strictest one.
2. Fill in Parts 1 to 5 from your own records. Use your legal name exactly as it appears on your state business filing. Contracts check it: Charlotte-Mecklenburg Schools’ February 2026 transportation request for proposals requires the insured’s name and address on the certificate to match the contract.
3. Order loss runs the same day. Ask every insurer from the last five years, in writing. Florida gives an insurer 15 calendar days to answer, and other states set their own clocks.
4. Pull a fresh driving record for every driver, owners included. See motor vehicle record for what it shows.
5. Collect the attachments in Part 7 into one file, and send the same package to each agent you ask for quotes.
6. Ask the Part 8 questions and write down each answer, who gave it, and the date.
7. Read the finished application before you sign it. Check every vehicle, driver, and yes or no answer against this checklist. The Maryland Insurance Administration’s guide (July 2024) notes that knowingly making a false statement on an insurance application is a fraudulent insurance act under Maryland law.
8. Keep it current. Update Parts 3 and 4 the day you add a van or a driver, and send the change to your agent and every broker before that van or driver carries a rider.

The template

Part 1: Your business

Item	Your answer
Legal name, and any trade name (DBA)
Business type (LLC, corporation, sole proprietor) and EIN
Mailing address, and every address where vehicles are garaged
Date the business started, and each owner’s years in passenger transportation
Contact for the agent: name, phone, and email
Industry code (special needs transportation is NAICS 485991)
NPI and Medicaid provider number
States and counties you serve
Days and hours you run trips, including after-hours service
Levels of service: ambulatory, wheelchair, stretcher, attendant
Who pays you: each broker, health plan, facility, public contract, and private pay
Your insurers for the last five years, with policy numbers and dates
Any policy declined, canceled, or not renewed in five years, and the reason

Part 2: How you operate

Question	Your answer
Trips per month in the last 12 months, by level of service
Trips per month you expect in the next 12 months
Farthest regular destination, in miles from your garage
Do any trips cross a state line?
Riders you carry: children, older adults, people with disabilities, stretcher riders
Do drivers help riders into and out of the vehicle, or into the building?
Where vans park overnight: indoor garage, locked lot, or street
Do drivers take vans home?
Do any drivers use their own cars for trips?
Do you use subcontractors or contract (1099) drivers?
Yearly payroll for drivers, and separately for dispatch and office staff
Gross receipts you expect in the next 12 months

Part 3: Vehicle schedule

One row per vehicle. Add rows as needed.

Unit	Year, make, model, and VIN	Seats and wheelchair positions	Lift, ramp, stretcher, or other equipment	Garaging ZIP code
1
2
3
4
5
6

Unit	Owned, leased, or financed	Lienholder or lessor	Value, including equipment
1
2
3
4
5
6

Part 4: Driver list

One row per driver, owners included.

Driver and date of birth	License state, number, and class	Years licensed, and date hired	Record pulled on	Crashes and violations, last 3 years

Part 5: Loss history

One row per policy year, most recent first.

Policy period	Insurer and policy number	Loss run requested on	Received on	Number of claims and total paid

Part 6: The coverage you need

Fill in each row from every contract’s insurance section, then compare the quotes against it.

Coverage	Highest limit any contract requires	Who requires it	Limit quoted
Auto liability
Auto physical damage (collision and comprehensive)
Medical payments
Uninsured and underinsured motorists
General liability, each occurrence and aggregate
Sexual abuse and molestation
Hired and non-owned auto
Umbrella or excess
Workers’ comp and employer’s liability
Professional liability
Crime or fidelity bond

Part 7: What to attach

Document	Attached (date)
Current declarations pages and policies
Loss runs from every insurer, last five years
Driving record for every driver
Registration, and title or lease, for every vehicle
Insurance section of each broker, plan, facility, and public contract
Driver hiring, training, and drug and alcohol testing policies
Vehicle inspection and maintenance records
Incident reports, and what you changed after each claim
Financial statements, if the agent asks
Written declinations from earlier insurers, if any

Part 8: Questions for your agent

Question	Answer, who gave it, and date
Which covered auto symbols are on the liability line, and do they meet every broker’s rule?
Does any policy carry a livery, for-hire, or public conveyance exclusion?
Is sexual abuse and molestation covered, excluded, or limited, and at what limit?
Are hired and non-owned autos covered?
Can each broker and facility be added as additional insured by endorsement, with its exact wording?
Can you add primary and non-contributory wording and a waiver of subrogation where contracts require them?
Which insurer writes each policy, is it licensed in my state or a surplus lines insurer, and what is its AM Best rating?
Does the auto policy cover the lift, ramp, and other equipment attached to each van?
Are loading and unloading riders covered?
How will the premium be audited, and on what basis: vehicles, payroll, or receipts?
How fast can you add a van and send each broker a new certificate?
Who gets notice if a policy is canceled, and how many days ahead?

The ACORD forms your agent fills in

ACORD, the insurance industry’s forms and data standards body, has published standard insurance forms since 1971. Its forms page says you must subscribe to an eligible forms program to download them, so your agent fills them in from what you supply and sends them to insurers. These are the forms a NEMT company’s application draws on, with the current editions in ACORD’s forms index revised September 8, 2026:

ACORD form	Title	Current edition
125	Commercial Insurance Application, Applicant Information Section	2025/03
127	Business Auto Section	2015/12
129	Vehicle Schedule	2009/11
163	Commercial Auto Driver Information Schedule	2012/06
137	Commercial Auto Coverages and Limits Section, one for each state	Varies by state, such as 2025/08 for Georgia
126	Commercial General Liability Section	2025/03
131	Umbrella Section	2017/11
130	Workers Compensation Application	2026/08
133	Workers Compensation Insurance Plan, Assigned Risk Section	2025/05

ACORD’s related forms list ties the Business Auto Section to the Vehicle Schedule, the driver schedule, and the state section, and ties the Applicant Information Section to the general liability, business auto, and umbrella sections. So one auto quote can mean five forms, and every one needs the same names, VINs, and license numbers. That is why Parts 1, 3, and 4 ask for them exactly.

Workers’ comp is priced on different facts. The Maryland Insurance Administration’s guide (July 2024) says a first workers’ comp premium depends on your payroll, the types of jobs your employees do (the classification), and your type of business, and that after a few years it may be based on your company’s own experience. That is why Part 2 splits driver payroll from office payroll. Workers’ comp for NEMT covers when you must carry it, and NEMT insurance audits explains how the payroll you estimate gets checked later.

Policy terms your brokers will check

Ask for coverage that fits your contracts the first time, so you are not shopping again after a broker turns down your certificate. Each broker sets its own limits, and NEMT insurance requirements lists them. These are the terms behind the Part 8 questions, as of October 2026:

• Covered autos. American Logistics will not accept a scheduled autos policy, and Verida’s Georgia provider page asks for all owned, hired, and non-owned autos. On a scheduled autos (symbol 7) policy written on ISO’s business auto coverage form (CA 00 01, 10 13 edition), a van you buy mid-term is covered only if you tell the insurer within 30 days, and only under the conditions commercial auto symbols explains.
• Insurer rating. American Logistics asks for an insurer rated B or better, and Verida’s Georgia page asks for A- or better. Get each quoted insurer’s rating in writing and check it against every contract.
• Abuse coverage. Modivcare calls sexual abuse and molestation coverage critical for work with vulnerable people and suggests higher limits where needed. Ask whether each general liability quote covers it, excludes it, or caps it below your contracts. See abuse and molestation coverage.
• Additional insured. SafeRide Health wants to be listed as additional insured on your certificate. Ask for each contract’s exact wording before the agent orders the endorsement.

Public contracts write their own terms. Charlotte-Mecklenburg Schools’ February 16, 2026 request for proposals asks for a $1 million combined single limit covering all owned (or scheduled), non-owned, and hired autos. If you lease vehicles from your own drivers, it wants each leased vehicle scheduled on your policy with its VIN on the certificate, and it no longer accepts certificates from drivers’ own auto policies. It also wants at least 30 days’ written notice of cancellation.

Why the livery question matters

A personal policy usually stops where paid rides begin. The California Department of Insurance’s notice to ride-hailing drivers explains why: a typical livery exclusion does not apply to a share-the-expense car pool, so insurers might deny coverage once a driver is paid more than that. That is why Part 2 asks whether any driver uses a personal car, and why the second question in Part 8 asks about every policy, not only your commercial auto. If a driver’s own car carries your riders, read using your own vehicle for NEMT and livery vehicle before the first trip.

What a loss run shows

Florida’s statute spells out what one contains. Under section 627.444 of the 2026 Florida Statutes, a loss run statement is a report with the policy number, the period of coverage, the number of claims, the paid losses on all claims, and the date of each loss. It does not include claim files or investigation reports, and the insurer does not have to give loss reserve information. The insurer must send it within 15 calendar days after it receives your written request, cover the last five years with that insurer, and tell your agent of record when it does. It may not charge for one statement a year.

Other states set different clocks. NEMT insurance denied lists the deadlines in Oregon, Illinois, and Pennsylvania. When the runs arrive, check each claim against your own incident reports and write a line on what you changed after it. The California guide says your claims history feeds the formula that sets your premium, so fix a wrong entry before an underwriter sees it. See loss runs.

A certificate does not change the policy

Brokers read your coverage from the certificate of insurance, but the policy decides what is covered. Texas puts this in law: its Department of Insurance’s certificate FAQ (last updated October 31, 2022) says a certificate may not alter, amend, or extend the coverage a policy provides (Texas Insurance Code section 1811.055).

So when a contract asks for additional insured status, a waiver of subrogation, or notice of cancellation, ask your agent for the endorsement that provides it, and keep a copy with the certificate. For what each coverage on your list will cost, see NEMT insurance cost.