BROKER S INFORMATION HANDBOOK for PREMIER MOVING & STORAGE PROGRAMS

Transcription

1 BROKER S INFORMATION HANDBOOK for PREMIER MOVING & STORAGE PROGRAMS TABLE OF CONTENTS INFORMATION COVERED PAGE NO. Welcome to TRANSGUARD Two General Information Three Submitting Applications Four Processing & Other Questions Five TRANSGUARD Guidelines for ACORD Forms & Their Uses Six Payment Procedures, Requirements & Guidelines Eight Claim Reporting Procedures, Requirements & Guidelines Ten Sample Forms List Twelve Actual Sample Forms After Page 12 Broker s Information Handbook August 2012 Edition Page 1 of 12

2 WELCOME TO TRANSGUARD TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. (TRANSGUARD) specializes in providing various insurance products to the transportation industry. The Premier Package Policy is specifically designed for the Relocation, Transportation and Storage Industries by people who understand these industries. TRANSGUARD has been writing these coverages since 1973, and the program is constantly being updated, revised, changed and improved. TRANSGUARD is one of the specialized insurance companies that comprise the IAT Reinsurance Group and is Rated A (Excellent) by A.M. Best. The accounts underwritten are involved primarily in the moving and/or storage of used household property and office property. Other contemplated operations include special products, logistics, records storage or information management, self storage, mobile self storage and freight forwarding. The annual premium size for package policies ranges from 5,000 to over 1,000,000. The TRANSGUARD Premier Package policy includes property, inland marine, general liability, auto liability, physical damage, and crime. Umbrella liability up to 5 Million over our primary package policy can also be included. Specifically designed coverage forms and rating methodology make the TRANSGUARD Premier Package Policy one of the most customer specific package policy available. Key personnel at TRANSGUARD have been active in the Moving & Storage Industry for over 40 years. They are actively involved with State and National Moving & Storage Associations and have advised both local and national regulatory agencies about the insurance needs, costs and coverages for the Moving & Storage Industry. TRANSGUARD strives to provide the best product and service to Broker and Mover clients. Constantly improving automation allows us to quote and issue policies and endorsements quickly and accurately. Special tools have been developed for Brokers that allow them to service their clients professionally. Special forms and materials have also been developed to help Policyholders understand and limit their losses. All underwriting, rating, and policy issuance functions for the Premier Programs are located at the TRANSGUARD office in Pasadena, California. Claims are handled out of our corporate headquarters in Naperville, Illinois. Broker s Information Handbook August 2012 Edition Page 2 of 12

3 GENERAL INFORMATION BROKER AGREEMENTS: In order to place business with TRANSGUARD, a broker must be properly licensed to transact business in the states in which coverage is written and operate in accordance with local state rules and regulations. Before an application can be accepted, a Broker Agreement must be in place between the broker and TransGuard General Agency, Inc. (TransGuard General), a sister company of TRANSGUARD. The basic commission on package policies is 10% and 5% for umbrella policies. To achieve more than the basic commission level, a combination of production and loss ratio factors are used. Exclusive producer appointments are not made by TRANSGUARD, but certain brokers may be designated as Key brokers by TransGuard General. Because of the their expertise in the Transportation Industry and premium volume, a Key broker may receive additional commission, marketing assistance, and direct contact referrals. HOW MULTIPLE SUBMISSIONS ARE HANDLED: In the vast majority of situations, TRANSGUARD will recognize the first in complete application when multiple submissions are received for an account. In order to be considered complete, an application must include the prior carrier loss runs. Any broker is free to call our office to find out if an application for a particular account has already been submitted. However, if two complete applications are received at about the same time, we will ask for an Authorization similar to a Broker of Record letter. A sample of this form is included in the forms appendix. Any similarly worded letter from the Policyholder is acceptable. ELIGIBILITY: The program insures companies primarily engaged in the used household goods or used office furniture, fixtures & equipment moving and storage business. Companies may engage in local, intermediate, or long haul trucking operations in conjunction with moving and storage operations. Other contemplated operations of the broader relocation industry include special products, logistics, records storage or information management, self storage and mobile self storage, and household goods freight forwarding. There are certain standard coverage restrictions and limitations for risks located in coastal or other areas where windstorms or hurricanes present a higher than average risk. TRANSGUARD is licensed to write insurance in 50 states plus the District of Columbia. Please check with our office for the latest status of our program filings and products available in a particular state. Broker s Information Handbook August 2012 Edition Page 3 of 12

4 SUBMITTING INFORMATION Applications, endorsement requests, and all supporting information should be e mailed to premier@transguard.com, or faxed to Once received, these are entered into a central computer system within 24 hours. If you want to know if something has been received or has been completed, virtually anyone who answers the phone can give you the information. We request that you use our application form because it contains all of the questions needed to properly underwrite and price our package policy. A fillable PDF copy of the current application can be downloaded from our website Look under For Our Brokers then select Broker Resources to find the latest Premier Program applications. Quotations are processed more quickly if the TRANSGUARD application is used, and better information usually results in better pricing. An ACORD application can be submitted along with additional information from our application. The TRANSGUARD application shows where an ACORD form may be substituted. Because of the state to state differences on the UM/UIM/PIP/etc., we request that along with the vehicle schedule you provide the ACORD 137 for the policyholder s principal state. The latest application forms are included in the Sample Forms section. ADDITIONAL INFORMATION: Along with a completed application, the following information must be included: 1. Four year premium & loss history. Please remember that if you can t read them or don t understand the loss runs, we probably won t either. 2. Financial Information. Larger accounts will require accountant prepared financial statements. In house reports are acceptable if they are complete. Tax returns or similar information is acceptable for smaller accounts. 3. For accounts in business less than five years, background and experience of principals or managers are normally required. The account must have experience in the state where coverage is requested. 4. Copies of the Bills of Lading (both local and long distance) and Warehouse Receipt forms generally used by the Policyholder in his (not his van line) operations are required. 5. For new business, current MVRs (driving record histories) for all drivers must be provided before a quote can be released. 6. If applicable, also submit copies of contracts with major customers, sub haul contracts, lease agreements and other types of contracts that could expand or limit coverage under our policy. TIMING OF SUBMISSIONS New Business: Fully completed applications should be transmitted 30 days prior to the desired effective date. Your application will be assigned to your underwriting team, reviewed, and a request will be Broker s Information Handbook August 2012 Edition Page 4 of 12

5 sent asking for any missing or additional information. We can, of course, quote accounts received less than 30 days prior to the effective date if time permits. For larger or unusual accounts, more time is recommended as these might require special approvals, reinsurance or a pre quote loss prevention inspection. TIMING OF SUBMISSIONS Renewals: Renewal solicitations are sent out approximately 90 days prior to policy expiration. You will be sent a renewal coverage schedule, fleet schedule, list of drivers, and a revenue breakdown form. These forms should make it easy for you to review current coverages and make any needed changes with your Policyholders. Renewal applications should be completed and returned as soon as possible prior to the renewal date. TRANSGUARD S new policy administration system allows for an automatic renewal process. As soon as we have reviewed and tested this process, we will also be advising you which accounts will be eligible for this process. If you request TRANSGUARD to non renew an account, you must notify us in the time frame required by your state for such cancellation or non renewal. This time period is generally from 30 to 60 days, but varies significantly by state. PROCESSING & OTHER QUESTIONS TRANSGUARD operates under a team office system. Currently each Underwriting Team consists of three to four members which include an underwriter, associate underwriter, or junior underwriters. If the principal underwriter is unavailable, a back up team member will always be available to answer your questions. The Policy Services Team is comprised of Underwriting Assistants who issue policies, endorsements, governmental filings, and maintain other policy records The Customer Service Team is always available to answer questions about billings, payments, cancellation and reinstatements, and this team also processes the input of all applications and endorsement requests. To reach any of our Teams, just use our toll free numbers: or Broker s Information Handbook August 2012 Edition Page 5 of 12

6 TRANSGUARD GUIDELINES FOR ACORD FORMS & THEIR USES TRANSGUARD has developed guidelines for brokers with respect to the use of the various industry standard forms. Please let us know if there are any form issues that we have missed. CERTIFICATES OF INSURANCE: ACORD 25 Certificate of Liability Insurance (05/2010) ACORD 24 Certificate of Property Insurance (09/2009) ACORD 23 Vehicle or Equipment Certificate of Insurance (05/2010) WHAT YOU CAN & CANNOT DO ON CERTIFICATES OF INSURANCE: Certificates of Insurance do not amend, alter or extend the policy. Therefore, Certificates must not be issued to extend coverage. Only policy forms or endorsements can amend or alter policy terms and conditions. On the newest ACORD form you can no longer indicate a notice of cancellation period. If Certificate Holders require that they be given specific number of days Notice of Cancellation, policies must be endorsed to reflect this grant. Please see TRANSGUARD forms , , and If an Additional Insured Endorsement is required for a moving project, you may use one of the two forms that are attached to the policy along with the General Liability Enhancement Endorsement. Use when there is a contract (or Bill of Lading) between the Policyholder and the Certificate Holder. Use when there is no contract. This is the form to use if the building owner requires the coverage, but the contract is between the Policyholder and the tenant. Brokers are not authorized to attach to a Certificate any endorsement that is not already on the policy. Nor are brokers authorized to issue any endorsement. If a loss payee, vehicle lessor/additional insured requires a Certificate for a specifically described or short term hired vehicle, you must attach a copy of the CA form issued along with the policy. This is our requirement even if you use the ACORD 23 form. If a mortgagee, loss payee, or landlord requires a Certificate of Insurance, the corresponding property, inland marine or general liability forms must be endorsed on the policy. Once these are on the policy, you can attach them to the requested Certificates of Insurance. If a van line requires evidence of insurance, you can issue a Certificate and attach the van line endorsement that is on the policy either the or the , depending upon the van line. In order to be considered valid, Certificates must be issued in accordance with these guidelines and be sent to us in a timely manner. This is especially important for since this one must be sent to TRANSGUARD prior to the commencement of work to start the 45 day time period of coverage. Broker s Information Handbook August 2012 Edition Page 6 of 12

7 POLICY CHANGE REQUESTS: Change requests can be made using an ACORD form or a simple e mail. Please make sure that your request contains all of the information necessary to process the endorsement. Endorsements can be processed quickly if all the information is complete. SPECIAL NOTES ABOUT AUTO CHANGES: 1. Unless a policy is on a special reporting basis, when a vehicle is added or deleted more than 30 days prior to the request date, verification may be required. Please review the reporting time conditions based on the Coverage Symbols on the policy! 2. If vehicles are used infrequently or are temporarily out of service, they can be written under our conditional use rating. This contemplates no more than 1,000 or 2,500 miles per year and is only applicable to commercial power units. If the policy is written with an Any Auto or equivalent Coverage Symbol, liability cannot be deleted for a not in use vehicle. Your underwriter may require verification of the limited mileage for any vehicles with the conditional use rating. 3. Short term leased vehicles are included in the non owned & hired coverage liability and physical damage coverage. There is a minimum 30 day charge for any owned vehicle added to the policy. 4. Many states currently require insurers of commercial vehicles to report the insurance coverage electronically. The states use this data for vehicle registration, so it is important that the vehicle identification number (VIN) information be accurate. 5. Personally owned private passenger vehicles cannot generally be covered on the fleet. Motorcycles and other recreational vehicles cannot be included for coverage. INSURANCE BINDER: As soon as you have received confirmation from your underwriter that coverage has been bound, you are authorized to issue this type of form. Please be sure to transmit a copy of any Binders issued to premier@transguard.com. VEHICLE ID CARDS: ID cards will be issued along with a new or renewal policy. As long as a specific vehicle is listed on the policy, the ACORD 50 or equivalent state form may be issued. Not all states accept ID cards as verification of insurance for registration or licensing. Remember that many states now require that insurance companies transmit the description, coverage, and name of insured electronically for coverage verification. Unless this information is exactly correct, policyholders may not be able to register the vehicles. Broker s Information Handbook August 2012 Edition Page 7 of 12

8 TRANSGUARD PAYMENT PROCEDURES, REQUIREMENTS & GUIDELINES PAYMENT TERMS: NEW OR RENEWAL POLICIES: The binding amount indicated on the quote must be remitted no later than ten (10) days after the effective date, or in the time period specified on the order form. Because of coverage changes, the actual calculated deposit (Installment #1) may be somewhat different than the amount shown on the quotation; any difference in the deposit must be paid within 30 days of the effective date. For new accounts, Governmental filings are not normally made until the binding amount has been received. You must let us know if filings are required before payment is received. ENDORSEMENTS: On the Order Form there are two ways that endorsements can be billed 1) added or subtracted from future installments, or 2) billed in full when the endorsement is issued. This choice must be made before the policy is issued, and may not be available for all situations. For choice #1, the revised installment amount will be due on the normal installment schedule. For choice #2, endorsements are due when billed. SPECIFIC PAYMENT SITUATIONS: THIRD PARTY PREMIUM FINANCING 1. It is the broker s responsibility to make premium financing arrangements, and to make sure that all of the information is correct. The binding amount must still be paid to us within 10 days with the balance of annual premium within 30 days of the effective date. 2. Any premium financing plan must reflect the 30 day notice of cancellation provision unless there are no government filings. 3. All premium financed accounts are agency billed. 4. If premiums are due for endorsements on a financed policy, it is the broker s responsibility to advise the finance company of these endorsement amounts, and to arrange for additional financing. CANCELLATIONS FOR NON PAYMENT 1. If the binding amount is not received within the specified period, the policy is subject to immediate cancellation. 2. Any premium payment that is returned or not honored by the bank (check, EFT or credit card) will result in immediate policy cancellation. Returned items are subject to a fee. (Based on state regulations, this fee may vary.) 3. If premiums are paid late so that TRANSGUARD does not have at least 30 days of equity in the policy, notice of cancellation will be sent. 4. When policies are cancelled for non payment, TRANSGUARD may also send Notice of Broker s Information Handbook August 2012 Edition Page 8 of 12

9 Cancellation to all interest holders. This would include Loss Payees, Additional Insureds, Van Lines, and all governmental filings. 5. Policies will not be reinstated until all past due and current premiums are paid. There is no fee to reinstate the policy, but there is a charge per filing to reinstate governmental filings. (Based on state regulations, this fee may vary.) PREMIUM BILLING TRANSACTIONS: MONTHLY STATEMENT OF BROKER BILLED ITEMS All Broker billings are on an ACCOUNT CURRENT basis. This means that all items billed in month #1 are due to TRANSGUARD on the 15 th day of month #2. Broker billed items are due under these terms even if the premium has not been collected from the policyholder. Because Customer or Direct Bill is our standard plan, your agency must have a special Addendum to the Broker Agreement in order to have the broker bill option. (This does not necessarily apply to premium financed policies.) Account Current Statements are sent on or about the first of every month. Premiums not paid on the terms described above will result in cancellation for non payment. MONTHLY CUSTOMER STATEMENTS A monthly statement is sent to each policyholder showing the total of all direct billed items that are outstanding. The statement or Invoice Summary shows the total balance due. Also included is a Customer Bill Policy List showing the amounts due for each policy. This statement is sent approximately 15 days prior to the Policyholder s cycle date that date is normally the monthly anniversary of the inception date. For example, a policy that is effective on the 18 th of the month will have a cycle date of the 18 th. Policies that are effective on the last few days of the month will have a cycle date of the 28 th. If the total of premiums is a credit due to the Policyholder, a check clearing all items will be issued approximately 5 days after the monthly cycle date unless other credit terms have been arranged. COMMISSIONS: 1. Commission can be retained from any broker billed transaction. 2. For transactions directly billed to the Policyholder, on or about the 5th of each month, a listing will be sent to you showing items paid by your policyholders during the prior month. If the total amount due you is more than 25.00, a check for the commission balance will be sent. (Amounts less than will be carried over to the next month.) 3. A statement showing return commissions due us will be generated and sent to you in this same manner. Broker s Information Handbook August 2012 Edition Page 9 of 12

10 TRANSGUARD CLAIM REPORTING PROCEDURES, REQUIREMENTS AND GUIDELINES GENERAL INFORMATION: All claims should be phoned in to (800) or be reported to the TRANSGUARD office in Illinois The various ACORD forms are acceptable, but some specific claim forms have also been developed. Those are all available at in the How to Report a Claim section. There is also a Frequently Asked Questions section be sure that agency staff and your policyholders are familiar with this feature. The Number One Rule is to report the claim to TRANSGUARD as soon as possible. FOR ALL TYPES OF CLAIMS: Make sure your policyholder understands what needs to be done when a claim first occurs: Get the complete story from the employees involved as soon as possible Keep a record of all employees involved in the incident. Gather all of the necessary paperwork. FOR SPECIFIC TYPES OF CLAIMS: The following paperwork is necessary for all cargo damage claims: The shipper s Statement of Claim form. Copy of the Bill of Lading, First Party Cargo Certificate, Master Moving Contract, or Agreement for Service, whichever form applies to the move and specifies the valuation option chosen by the shipper along with inventories and exception sheets if available. Complete description of the incident and all parties involved. The following paperwork is necessary for all storage damage claims: The customer s Statement of Claim form. Copy of the Warehouse Receipt, First Party Storage Certificate, Storage Contract, Inventory, or other documents outlining the owner of the property and our Policyholder s liability for the property and specifying the valuation option chosen by the owner of the property. Information on how long the property has been in the warehouse and if the owner of the property has had any access to the property while in storage. Complete description of the incident and damages. Broker s Information Handbook August 2012 Edition Page 10 of 12

11 The following paperwork is necessary for all general liability, auto liability & physical damage claims: A completed claim form. If a vehicle was being used to haul cargo, a copy of the Bill of Lading, Master Moving Contract, or Agreement for Service, whichever form applies to the move. Description of the vehicle year, make, and Vehicle ID Number, and fleet schedule item number. Description of other equipment involved in the claim (for example, fork lift, dolly, etc.) Complete description of the incident and all parties involved. A copy of the police report, if one has been made. The following paperwork is necessary for property or crime claims: A completed claim form. A copy of the police report, if one has been made. Complete description of the incident and all parties involved. SPECIAL INFORMATION: The policyholder does have limited authority to settle cargo, warehouse, and property damage claims that are under his deductible or up to 250 over the deductible. However, if the amount claimed exceeds the deductible by more than 250; if the claimant does not agree to a settlement within a reasonable period of time (this period of time is specified in some state tariffs, and in no case should exceed 30 days); or if the claimant is represented by an attorney, the claim must be reported as soon as possible. In many moving tariffs, the mover is granted certain rights and responsibilities for claim settlement. These rights and responsibilities do not transfer to an insurance agent or an insurance company. As an insurance company, TRANSGUARD is bound by the claim settlement guidelines (fair claim practices) that all insurance companies are legally mandated to follow. This means that TRANSGUARD must investigate all claims presented, and may pay claims that might be denied under a state s moving tariff depending on the individual circumstances of the claim or the additional costs to investigate and settle the claim. If there is any suspicion of claim fraud, please ask that TRANSGUARD S Special Investigative Unit review the claim. Broker s Information Handbook August 2012 Edition Page 11 of 12

12 SAMPLE FORMS Following are specimen copies of the forms that have been referred to in this Handbook Authorization for TRANSGUARD Quotation Package Policy Application and Instructions Operations Supplemental Application L Long Haul Trucking Supplemental Application Transit Insurance Program Supplemental Application S Sub Haul/Owner Operators Supplemental Application ACORD 25 Certificate of Liability Insurance ACORD 24 Certificate of Property Insurance ACORD 23 Vehicle or Equipment Certificate of Insurance ACORD 50 Vehicle Identification Card Additional Insured Insured Contracts Additional Insured Designated Person or Organization 45 Day Coverage Additional Insured Amendment of Cancellation Provisions Additional Insured Amendment of Cancellation Provisions Additional Insured Additional Insured Van Line Additional Insured Van Line Operations Claimant s Damage Report Claimant s Report of Auto Accident Statement of Claim (Cargo or Warehouse) Physical Damages First Report Please note that the edition dates shown on the following individual forms may change as forms are updated. There may be different edition dates in a particular state or there may be state specific versions of some of the TRANSGUARD forms. Check which version is attached to any particular policy. Broker s Information Handbook August 2012 Edition Page 12 of 12

13 AUTHORIZATION FOR TRANSGUARD QUOTATION Only one quotation will be provided to a mover. The price of the insurance depends upon the coverages and options selected by a particular broker. However, if all specifications are the same, the same price would be quoted to any broker. You must select only one broker to represent your insurance specifications to TRANSGUARD. I understand that only one broker may receive a quotation from TRANSGUARD, and authorize the following broker to represent us: Name of Individual Producer: Name of Insurance Agency: Address of Insurance Agency: Name of Applicant Policyholder: Address of Company: Authorized By: (Signature and Title) This Authorization is effective: and expires ninety (90) days after this date unless coverage is written by TRANSGUARD or a superseding Authorization is received /12

14 PREMIER PROGRAM APPLICATION INSTRUCTIONS AND NOTES TRANSGUARD can provide specific coverage for the following relocation industry operations conducted on a local, intermediate or long-haul basis: Household Goods Moving & Storage; Office & Industrial Moving & Storage; Special Products/Logistics Moving & Storage; Information Management/Records Storage; Self Storage or Mobile Self Storage; Freight Forwarding The following lines of coverage can be written: Property and Business Income; Inland Marine including Cargo, Warehouse, Equipment & EDP; General Liability; Commercial Automobile Liability & Physical Damage; Crime and Fidelity; Umbrella; First-party Transit Insurance. (Other coverage types are written in our Independent Contract programs contact our Kansas City Office.) In addition to the Basic Policy Application, please include the ACORD 137 for Commercial Auto Coverage. Include ACORD 67 for Commercial Property Coverage in the states of Illinois, Indiana, Kentucky and West Virginia. There are also Supplemental Applications for Long-Haul exposures, the Transit Insurance Program, and one summarizing the specific kinds of operations conducted by the applicant. Please use ACORD 131 for Umbrella coverage. Once completed, the information should be ed to Premier@TransGuard.com. Please also include the following additional information for new accounts: o o o o MVRs for all drivers indicated on the driver s list Most current Financial Statement Four years of currently-valued company loss runs for all lines of business being quoted, along with premiums charged Samples of Bills of Lading, Warehouse Receipts, Storage Contracts, and other major contracts used in the insured s operation Additional information required for renewal accounts: o o o MVRs for any new drivers or those with a borderline or poor rating last year Most current Financial Statement; current Revenue Breakdown Updated loss runs from any prior carrier (other than TRANSGUARD) in the four year experience period SPECIAL NOTE: Fully-completed ACORD Application Forms may be substituted for many of the pages in the Basic Policy Application. The acceptable ACORD form is noted on each page where a substitution is allowed. There may be questions or specific coverage options on the TRANSGUARD page that are not on the ACORD page, so please review the Basic Policy Application pages carefully. The TRANSGUARD Inland Marine Section, Revenue Breakdown, and Operations Supplement are always required. Your underwriter may, of course, ask for additional information once the submission has been received and reviewed Notes 03/11 PREMIER PROGRAM APPLICATION INSTRUCTIONS Page 1 of 1

15 PACKAGE POLICY APPLICATION PRODUCER: INSTRUCTIONS: Complete all pages for coverage requested. Submit completed application to the TRANSGUARD Premier Programs Office together with prior carrier loss runs, financial statement, MVR s and other pertinent information. 301 N. Lake Avenue, Suite 400, Pasadena, CA Premier@TransGuard.com POLICY INFORMATION NEW RENEWAL RE-WRITE PROPOSED EFFECTIVE DATE PROPOSED EXPIRATION DATE QUOTE ISSUE APPLICANT INFORMATION NAME: MAILING ADDRESS: (Please provide a complete list of Named Insureds on additional sheet if necessary.) PHONE NUMBER: FAX NO: ADDRESS: TAX ID NUMBER: INSPECTION CONTACT PERSON & PHONE NO. CLAIMS HANDLING CONTACT PERSON & PHONE NO. DESCRIPTION OF OPERATIONS Form of Company: INDIVIDUAL PARTNERSHIP CORPORATION JOINT VENTURE LIMITED LIABILITY COMPANY (LLC) TRUST Relocation & Storage Industry Operation: (Please show the approximate percentage of each type of operation) % HOUSEHOLD GOODS % OFFICE & INDUSTRIAL % SPECIAL PRODUCTS % INFORMATION or RECORDS STORAGE % FREIGHT FORWARDER % SELF-STORAGE or MOBILE SELF-STORAGE % OTHER PREMISES INFORMATION (Attach additional schedule of locations if necessary) LOC. # STREET, CITY, COUNTY, STATE, ZIP CODE INTEREST YEAR BUILT PART OCCUPIED Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % Owner Tenant % /11 PACKAGE POLICY APPLICATION Page 1 of 11

16 GENERAL INFORMATION SECTION APPLICANT NAME: REQUESTED EFFECTIVE DATE: GENERAL INFORMATION (Explain all Yes responses in remarks.) 1. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? NO YES DOES THE APPLICANT HAVE ANY SUBSIDIARIES? (List all Subsidiary names) NO YES 2. HOW LONG HAS THE APPLICANT BEEN IN BUSINESS? YEARS 3. WHAT ARE THE NORMAL HOURS OF OPERATION? TO 4. WAS THERE ANY MAJOR CHANGE IN OWNERSHIP OR ANY BANKRUPTCIES IN THE PAST FIVE YEARS? NO YES 5. WERE THERE ANY PAST LOSSES OR CLAIMS RELATING TO DISCRIMINATION OF ANY KIND OR FOR NEGLIGENT HIRING? NO YES 6. IS THE APPLICANT A VAN LINE AGENT? Name of Van Line: No Affiliation 7. WERE ANY POLICIES DECLINED, CANCELED OR NON-RENEWED WITHIN THE PAST 3 YEARS? NO YES 8. IS A FORMAL SAFETY PROGRAM IN OPERATION? NO YES 9. DOES APPLICANT DO ANY MOVING AND/OR STORAGE OF HIGH-VALUED OR TARGET ITEMS? NO YES 10. DOES APPLICANT EVER ISSUE FIRST PARTY CERTIFICATES FOR TRANSIT OR STORAGE? NO YES IF YES, IS THERE A SEPARATE POLICY FOR THIS? NO YES 11. PLEASE DESCRIBE PRE-EMPLOYMENT SCREENING PROCESS CRIMINAL BACKGROUND CHECK EMPLOYMENT HISTORY FINANCIAL BACKGROUND CHECK MVRS 12. ATTACH COPIES OF ANY BILLS OF LADING, MOVING CONTRACTS, MASTER MOVING AGREEMENTS, WAREHOUSE RECEIPTS, & STORAGE CONTRACTS ISSUED IN THE NAME OF THE APPLICANT. AUTOMOBILE/TRUCKERS INFORMATION Explain any (*) answers in separate remarks. 1. ARE ANY VEHICLES TO BE COVERED OWNED BY OTHERS? NO YES(*) 2. ARE ANY OWNED VEHICLES NOT LISTED? NO YES(*) 3. ARE ANY VEHICLES LOANED OR RENTED TO OTHERS? NO YES(*) 4. ARE THERE ANY OWNER OPERATORS, CONTRACTORS, OR SUBHAULERS? NO YES(*) 5. IS THERE A FORMAL, DOCUMENTED VEHICLE MAINTENANCE PROGRAM? NO(*) YES 6. IS THERE A PRE-EMPLOYMENT SCREENING PROGRAM? NO(*) YES DOES A SCREENING PROCESS INCLUDE ANY OF THE FOLLOWING? Written Test Road Test Drug Testing MVR Screening Verification of Prior Employment History Criminal Background Check Other 7. ARE ALL EMPLOYEES COVERED FOR WORKERS COMPENSATION? NO(*) YES 8. ARE TRAILERS REGULARLY RENTED? NO YES(*) 9. ARE POWER UNITS REGULARLY RENTED? NO YES(*) 10. DOES APPLICANT PARTICIPATE IN U.I.I.A.? NO YES(*) 11. ARE PRIVATE PASSENGER VEHICLES DRIVEN BY NON-EMPLOYEES OR FAMILY MEMBERS? NO YES(*) 12. IS THERE A FORMAL PRE-TRIP VEHICLE INSPECTION ROUTINE? NO YES(*) 13. IF THE APPLICANT IS A VAN LINE AGENT, DOES THE VAN LINE PROVIDE AUTO LIABILITY COVERAGE TO THE NO YES APPLICANT WHEN OPERATING UNDER VAN LINE AUTHORITY? 14. DO THE APPLICANT S VEHICLES OPERATE ACROSS STATE LINES? NO YES 15. DO THE APPLICANT S VEHICLES EVER OPERATE OUTSIDE OF THE UNITED STATES? NO YES PLEASE ATTACH AN EXTRA PAGE FOR ANY QUESTIONS REQUIRING ADDITIONAL REMARKS. Please use ACORD 45 to show all Additional Interests on the policy /11 PACKAGE POLICY APPLICATION Page 2 of 11

17 PROPERTY SECTION APPLICANT NAME: Please complete one page for each building - Blanket Coverage is not available. If there are multiple buildings at one location, attach a diagram. REQUESTED EFFECTIVE DATE: COMPLETE ADDRESS OF LOCATION NO., BUILDING NO. : ACORD 140 may be substituted for the basic property information. Please also complete ACORD 62 OK for any Oklahoma locations. PHYSICAL DESCRIPTION OF LOCATION: CONSTRUCTION TYPE: Concrete Tilt-Up Concrete Block All Metal Frame & Metal Brick Frame or Stucco Other ROOF TYPE & SHAPE: Wood Asphalt Metal Concrete Flat Dome/Peak Other PHYSICAL PROTECTION: Fire Sprinkler System Smoke or Fire Alarms Fire Extinguishers Motion Detectors (Check all that apply) Central Alarm Local Alarm Guard Service Bars or Dead Bolts Fire Walls/Parapets Other OCCUPANCY & SIZE: Office Only Warehouse Only Basement Number of Stories: Office & Warehouse Utility or Storage Elevator(s) Other Other (Describe) Year Built: (*) (*) If built before 1990 show year of updates to: Wiring Roofing Plumbing Heating Other: Is there physical separation between Applicant and other occupants of the building? Does Applicant lease any space to unrelated businesses? If yes please describe in remarks Are you required to provide building coverage for leased locations? If Yes who provides building maintenance? If Yes does the lease waive right of recovery against landlord? COVERAGE LIMITS REQUESTED PROPERTY SECTION DEDUCTIBLE: (500. Minimum Deductible) TYPE OF COVERAGE LIMIT OF LIABILITY Total Area of Building: Total Occupied by Insured: Insured s Office Size: Insured s Warehouse Size: Occupied by Others (**): (**) List other occupants in remarks Yes Yes Yes You Yes FORMS CONDITIONS VALUATION (*) CO- INSURANCE BUILDING ACV RCV AV FV % BUSINESS PERSONAL PROPERTY Office ACV RCV AV FV % BUSINESS PERSONAL PROPERTY Other than Office Property ACV RCV AV FV % TENANTS IMPROVEMENTS & BETTERMENTS ACV RCV AV FV % OTHER: ACV RCV AV FV % BUSINESS INCOME & EXTRA EXPENSE Storage Revenue Only BUSINESS INCOME & EXTRA EXPENSE Other than Storage Revenue Including Including Excluding Payroll Excluding Payroll (*) ACV = Actual Cash Value; RCV = Replacement Cost Value; AV = Agreed Value; FV = Functional Valuation % % No No No Landlord No SQ.FT. SQ.FT. SQ.FT. SQ.FT. SQ.FT. OPTIONS /11 PACKAGE POLICY APPLICATION Page 3 of 11

18 INLAND MARINE SECTION APPLICANT NAME: (Use ACORD 145 for Valuable Papers or Accounts Receivable stand alone coverages.) REQUESTED EFFECTIVE DATE: INLAND MARINE SECTION DEDUCTIBLE: (500. Minimum Deductible) WAREHOUSE LIABILITY COVERAGE (If more than 5 warehouses, attach schedule for additional locations) LOC. NO. LIMIT REQUESTED (Minimum Limit may be required) AREA OF WAREHOUSE (Square Feet) USE OF WAREHOUSE SPACE (Show % of each usage and vault stacking arrangement 1 high, 2 high, etc.) % Unused % Vaults High % Racks % Loose % Unused % Vaults High % Racks % Loose % Unused % Vaults High % Racks % Loose % Unused % Vaults High % Racks % Loose % Unused % Vaults High % Racks % Loose % Unused % Vaults High % Racks % Loose Check Types of Property Warehoused: Household Goods New Furniture Office Property Electronics High-Value Property Check all that apply Business Records Military Property Store Furnishings or Equipment Freight of All Kinds Average Value of Property Warehoused: % At a per box, package or file limited liability % At 3.00 per pound valuation or lower % On an Actual Cash Value Basis % On a Replacement Cost Basis (See specific questions on % More than 3.00 per pound or Declared valuation % Other (describe) Operation Supplement) Entries above should total 100% Entries above should total 100% CARGO LIABILITY COVERAGE Any One Loss Limit: 50, , , , , , , ,000. 1,000,000. Aggregate In Transit Limit: 100, , , , , , , ,000. 1,000,000. Check Types of Property Transported: Household Goods New Furniture Office Property Electronics High-Value Property Check all that apply Business Records Military Property Store Furnishings or Equipment Freight of All Kinds Valuation of Property Transported: % At a per box, package or limited liability % At 3.00 per pound valuation or lower % More than 3.00 per lb or Declared valuation Entries above should total 100% % On an Actual Cash Value Basis % On a Replacement Cost Basis % Other (describe) Entries above should total 100% Breakdown of Method of Transport: % Owned Vehicles % Contractor Vehicles % By Rail % By Water % By Air % Non-Truck or On-Premises Moves Entries above should total 100% Total Transportation Revenues: % Applicant s Authority or Direct Contracts (Revenue Breakdown must also be completed) MOBILE EQUIPMENT & COMPUTER COVERAGE COVERAGE LIMITS: EQUIPMENT & TOOLS: Actual Cash Value Basis or COMPUTERS & ELECTRONIC EQUIPMENT: Replacement Cost Basis Is there any mobile equipment with values greater than 25,000? Yes No Is any of the mobile equipment licensed for road use? Yes No Are there any vehicles that are used only within the policyholder s premises? (Yard Dogs, etc.) Yes No Explain any Yes answers in remarks /11 PACKAGE POLICY APPLICATION Page 4 of 11

19 GENERAL LIABILITY SECTION APPLICANT NAME: REQUESTED EFFECTIVE DATE: COVERAGES LIMITS COMMERCIAL GENERAL LIABILITY ACORD 126 may be substituted for the following information: CLAIMS MADE OCCURRENCE GENERAL AGGREGATE DEDUCTIBLE OPTIONS (500 Minimum) PRODUCTS & COMPLETED OPS. AGGREGATE PROPERTY DAMAGE Per Claim PERSON & ADVERTISING INJURY BODILY INJURY Per Occurrence EACH OCCURRENCE BI PD COMBINED DAMAGE TO RENTED PREMISES MEDICAL PAYMENTS (Any One Person) EMPLOYEE BENEFITS LIABILITY EACH EMPLOYEE LIMIT DEDUCTIBLE EACH EMPLOYEE AGGREGATE LIMIT Number of Employees: Number of Employees Covered by Benefit Plans: Retroactive Date: STOP GAP EMPLOYERS LIABILITY BODILY INJURY BY ACCIDENT: EACH ACCIDENT BODILY INJURY BY DISEASE: EACH EMPLOYEE BODILY INJURY BY DISEASE: POLICY LIMIT TOTAL PAYROLL IN MONOPOLISTIC STATES: SCHEDULE OF HAZARDS (Attach additional schedule if required) LOCATION NO CLASSIFICATION CLASS CODE BASIS (*) EXPOSURE TERRITORY (*) S = GROSS SALES PER 1,000 SALES P = PAYROLL PER 1,000 PAYROLL GENERAL INFORMATION A = AREA PER 1,000 SQ FT C = TOTAL COST PER 1,000 COST M = ADMISSIONS PER 1,000 ADMISSIONS (Explain any Yes responses in attached remarks for current or past operation.) 1. Does the Applicant have any operations that are not included for coverage? 2. Does the Applicant maintain any parking facilities that are NOT adjacent to specified locations? 3. Does the applicant provide any medical facilities or have any medical employees? 4. Is the Applicant operating as a vehicle rental agent? (Ryder, U-Haul, etc.) 5. Are forklifts or other lifts transported to jobsites? 6. Does the Applicant have more than an incidental rigging or crane liability exposure? 7. Does the Applicant have any vehicle repair operations? 8. Is any of the Applicant s machinery or equipment loaned or rented to others? 9. Does the Applicant have any owned or leased aircraft or watercraft? 10. Does the Applicant sponsor any teams or sporting or social events? 11. Does the Applicant lease employees to other companies? Or lease employees from an employee leasing company? 12. Is there a formal and written safety and security policy in place? 13. Does any advertising make representations about the safety or security of the Applicant s premises? 14. Do any of the Applicant s premises have on-site residents? Or any residential units? U = UNIT PER UNIT T = OTHER YES NO /11 PACKAGE POLICY APPLICATION Page 5 of 11

20 AUTO LIABILITY & PHYSICAL DAMAGE SECTION APPLICANT NAME: A State-Specific ACORD 137 must also be supplied for the auto exposures REQUESTED EFFECTIVE DATE: DEDUCTIBLE OPTIONS LIABILITY DEDUCTIBLE Per Accident PHYSICAL DAMAGE Service Use or Private Passenger Type Vehicles Comprehensive Collision BODILY INJURY Per Person PHYSICAL DAMAGE Commercial Vehicles Per Accident Comprehensive Specified Causes of Loss PROPERTY DAMAGE Per Accident Collision COVERAGES AND LIMITS COMBINED SINGLE LIMIT BODILY INJURY AND PROPERTY DAMAGE PERSONAL INJURY PROTECTION ADDED PERSONAL INJURY PROTECTION or BASIC FIRST PARTY BENEFIT MEDICAL PAYMENTS UNINSURED MOTORIST Please describe any state-specific coverage requirements on attached ACORD 137 Any Auto Non-Owned Autos Please describe coverage requirements on attached ACORD 137 STATUTORY LIMIT UNINSURED MOTORIST PROPERTY DAMAGE Include Do not include UNDERINSURED MOTORIST Please describe any state-specific coverage requirements on attached ACORD 137 STATUTORY LIMIT Specifically Described Autos Hired Autos All Power Units Eligible Private Passenger Vehicles (*) Specifically Described Vehicles All Power Units Eligible Private Passenger Vehicles (*) Specifically Described Vehicles All Power Units Eligible Private Passenger Vehicles (*) Specifically Described Vehicles PHYSICAL DAMAGE OWNED COMMERCIAL VEHICLES Actual Cash Value Basis PHYSICAL DAMAGE DEDUCTIBLES SHOWN ABOVE or Stated Value Basis SPECIFY DIFFERENT DEDUCTIBLES OWNED PRIVATE PASSENGER VEHICLES(*) Actual Cash Value Basis PHYSICAL DAMAGE DEDUCTIBLES SHOWN ABOVE or SPECIFY DIFFERENT DEDUCTIBLES TRAILER INTERCHANGE Limit in Enhancements PHYSICAL DAMAGE DEDUCTIBLES SHOWN ABOVE or SPECIFY DIFFERENT DEDUCTIBLES HIRED COMMERCIAL VEHICLES Limit in Enhancements PHYSICAL DAMAGE DEDUCTIBLES SHOWN ABOVE or SPECIFY DIFFERENT DEDUCTIBLES OTHER COVERAGE Drive Other Car (specify names and relationships) Garagekeepers (*) Eligible Private Passenger Vehicles are those Owned by the Named Insured and used principally in the applicant s business. Private Passenger vehicles with personal use are not generally eligible. PLEASE ATTACH AN EXCEL SPREADSHEET OF VEHICLES TO BE INSURED This should include year, description, VIN, radius of operation, and coverage required. Please also indicate any vehicle that is covered for auto liability by the van line while operating under van line dispatch /11 PACKAGE POLICY APPLICATION Page 6 of 11

21 CRIME SECTION APPLICANT NAME: ACORD 141C may be substituted for this page. REQUESTED EFFECTIVE DATE: COVERAGE FORM AND TITLE LIMIT DEDUCTIBLE EMPLOYEE THEFT Blanket Schedule ERISA FORGERY OR ALTERATION INSIDE THE PREMISES-THEFT OF MONEY & SECURITIES All Locations Designated Locations INSIDE THE PREMISES ROBBERY OR SAFE BURGLARY OF OTHER PROPERTY All Locations Designated Locations OUTSIDE THE PREMISES Money & Securities Other Property All Locations Designated Locations COMPUTER FRAUD FUNDS TRANSFER FRAUD MONEY ORDERS & COUNTERFEIT PAPER MONEY OTHER COVERAGE FORMS OR ENDORSEMENTS: Name of Plan: ERISA EMPLOYEE THEFT PLAN VALUE: Number of Plan Participants: Number of Trustees of Employees handling Plan Assets: Is there a Licensed Securities Firm responsible for investing plan funds? Yes No NUMBER OF EMPLOYEES INDICATE THE NUMBER OF ALL EMPLOYEES AND COVERED CONTRACT DRIVERS AT ALL LOCATIONS WHO HANDLE OR HAVE CUSTODY OF MONEY, CREDIT CARDS, CHECKS OR SECURITIES, OR OTHER PROPERTY TO BE COVERED UNDER THIS SECTION. INDICATE THE NUMBER OF OWNERS OR OFFICERS: TOTAL NUMBER OF OTHER EMPLOYEES: CONTROLS AND PROCEDURES Audits conducted by Staff CPA Public Accountant Other Audits Frequency: Annual Semi-Annual Quarterly Other Are all locations audited? Yes No Audit Conducted within G.A.A.P.? Yes No Bank accounts are reconciled by a person not authorized to deposit or Is countersignature of checks required? Yes No withdraw funds? Yes No If no, who signs controls? Bank deposits made Daily Every Other Day Weekly Bank deposits made by Employees Owners Bank Courier New employees who will have access to cash or checks are screened for: Credit Employment Criminal Other MONEY & SECURITIES Enter the exposure for each category. Amounts shown should be maximum exposure TYPE MONEY CHECKS FOR DEPOSIT ACCOUNTS PAYABLE CHECKS Are securities subject to joint control of two or more responsible employees? Yes No PAYROLL CHECKS MONEY OVERNIGHT SECURITIES (IN SAFE DEPOSIT) INSIDE MESSENGER MISCELLANEOUS AND SECURITY INFORMATION HOURS OF OPERATION CHECKS STAMPED FOR DEPOSIT ONLY? NIGHT DEPOSITORY? ALL PREMISES HAVE DEAD BOLT LOCKS? Yes No Yes No Yes No TYPE & DESCRIPTION OF SAFES OR VAULTS TYPE & DESCRIPTION PREMISES ALARM MESSENGER PROTECTION UL SMNA Round Door Local Central Station Police Connect Number of Messengers: Square Door Class: Grade & Certificate No.: (Attach Copy) Guarded? Yes No /11 PACKAGE POLICY APPLICATION Page 7 of 11

22 REVENUE SUMMARY BREAKDOWN These figures are ACTUAL or ESTIMATED for the period: to TYPE OF REVENUE LOCAL MOVING OR HAULING (Within 100 Miles) HOUSEHOLD GOODS MILITARY PERSONAL PROPERTY OFFICE FURNITURE, FIXTURES OR EQUIPMENT SPECIAL PRODUCTS BUSINESS RECORDS PICK UP & DELIVERY STORAGE TO GO PICKUP & DELIVERY FREIGHT FORWARDING DRAYAGE REGIONAL MOVING (Within Miles) HOUSEHOLD GOODS MILITARY PERSONAL PROPERTY OFFICE FURNITURE, FIXTURES OR EQUIPMENT SPECIAL PRODUCTS BUSINESS RECORDS PICK UP & DELIVERY STORAGE TO GO PICKUP & DELIVERY FREIGHT FORWARDING DRAYAGE LONG-HAUL MOVING (More than 300 Miles) HOUSEHOLD GOODS MILITARY PERSONAL PROPERTY OFFICE FURNITURE, FIXTURES OR EQUIPMENT SPECIAL PRODUCTS BUSINESS RECORDS PICK UP & DELIVERY STORAGE TO GO PICKUP & DELIVERY FREIGHT FORWARDING DRAYAGE ON-PREMISES MOVING OR INSTALLATION AIR FREIGHT INTERNATIONAL MOVING PACKING AND/OR CRATING STORAGE OR WAREHOUSING HOUSEHOLD GOODS MILITARY PERSONAL PROPERTY OFFICE FURNITURE, FIXTURES OR EQUIPMENT SPECIAL PRODUCTS BUSINESS RECORDS SELF STORAGE OR CONTAINERIZED SELF STORAGE WAREHOUSE HANDLING OR S.I.T. CHARGES OTHER SALES OPERATIONS BOOKING COMMISSIONS OR FEES VALUATION OR INSURANCE CHARGES CONSULTING SERVICES OTHER INCOME (Describe) TOTAL REVENUE FROM ALL SOURCES: AMOUNT OF REVENUE % of Revenue from Direct Contract or Authority % of Revenue under Van Line or Other Authority /11 PACKAGE POLICY APPLICATION Page 8 of 11

23 PRIOR CARRIER PREMIUM & LOSS INFORMATION APPLICANT NAME: Page 2 of ACORD 125 may be substituted for this information REQUESTED EFFECTIVE DATE: TYPE OF COVERAGE PROPERTY POLICY PERIOD INSURANCE CO. PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: 1 ST PRIOR 2 ND PRIOR 3 RD PRIOR 4 TH PRIOR INLAND MARINE PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: GENERAL LIABILITY PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: AUTO LIABILITY, UM/UIM, MEDICAL PAYMENTS, PIP PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: PHYSICAL DAMAGE OTHER: UMBRELLA CRIME PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: PREMIUMS: LOSSES: EXPENSES: # OF CLAIMS: SPECIFIC LOSS INFORMATION (Legible loss runs MUST be attached) ENTER ALL CLAIMS OR OCCURRENCES THAT ARE PAID OR RESERVED AT GREATER THAN 7,500. (ATTACHED LOSS RUNS ARE ACCEPTABLE) DATE OF LOSS COVERAGE TYPE DESCRIPTION OF INCIDENT AMOUNT PAID AMOUNT RESERVED /11 PACKAGE POLICY APPLICATION Page 9 of 11

24 DRIVING RECORD INFORMATION (Attach additional list if required) APPLICANT NAME: REQUESTED EFFECTIVE DATE: PLEASE ALSO ATTACH A RECENT COPY OF THE MOTOR VEHICLE RECORD (MVR) FOR EACH DRIVER NAME OF EMPLOYEE LICENSE NUMBER STATE CLASS DATE OF BIRTH DATE OF HIRE SIGNATURES AND FRAUD WARNINGS Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CA, CO, HI, KY, LA, NJ, OH, OK, and PA) In DC, VA and WA, insurance benefits may also be denied. In Florida, Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. In New York for Commercial Insurance Applicants Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In New York for Commercial Automobile Applicants Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicle or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. APPLICANT S SIGNATURE DATE SIGNED PRODUCER S SIGNATURE DATE SIGNED /11 PACKAGE POLICY APPLICATION Page 10 of 11

25 ADDITIONAL FRAUD STATEMENTS IN CALIFORNIA FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. IN COLORADO IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. IN DISTRICT OF COLUMBIA WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. IN HAWAII FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT ANY PERSON WHO PRESENTS A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS GUILTY OF A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. IN KENTUCKY ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. IN LOUISIANA ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. IN NEW JERSEY ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. IN OHIO ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. IN OKLAHOMA WARNING ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. IN PENNSYLVANIA FOR COMMERCIAL AUTOMOBILE APPLICANTS ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND THE PAYMENT OF A FINE OF UP TO 15,000. IN PENNSYLVANIA FOR COMMERCIAL INSURANCE APPLICANTS ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. IN VIRGINIA AND WASHINGTON IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS /11 PACKAGE POLICY APPLICATION Page 11 of 11

26 OPERATIONS SUPPLEMENTAL APPLICATION APPLICANT NAME: REQUESTED EFFECTIVE DATE: SPECIFIC OPERATIONS CONDUCTED BY APPLICANT (Check all that apply): Used Household Goods Moving or Storage Used Electronics Moving or Storage Military Household Goods Moving or Storage New Household Goods Moving or Storage New Electronics Moving or Storage Used Office/Store Furniture or Fixtures Moving or Storage Packing & Crating High-Value Product Moving or Storage New Office/Store Furniture or Fixtures Moving or Storage Packing Material Sales Antiques/Fine Arts Moving or Storage Installation of Office Systems or Partitions Overflow or temporary storage for others Drayage or Hauling Design of Office Systems or Partition Layouts Agent of National Van Line Company Cross-Dock Operation Logistics & Distribution Transportation and/or Storage Agent of Freight Forwarding Company Air Freight Moving or Storage of Museum Fixtures or Exhibits Pickup and Storage of Records Household Goods Freight Forwarding Customer Packed Storage Container Pickup & Delivery On-Site or Off-Site Data Destruction Commodities Freight Forwarding Containerized (vault boxes or pods ) Self-Storage Backup of Customer s Computer Files Licensed Customs House Broker Standard (Packed By Owner) Self-Storage Exhibits and Display Moving or Storage Freight Consolidation/NVOCC Piano or Musical Instrument Moving or Storage Other (Describe): Theatrical or Cinema Moving or Storage OPERATION INFORMATION: What is Applicant s Average Revenue per move: What is the average number of moves per week per truck: LICENSES, PERMITS, or CERTIFICATES and REFERENCE OR DOCKET NUMBERS: (Check all that apply and show permit numbers) PUC or DOT State: # SDDC for: Transit For Transit show SCAC # PUC or DOT State: # Storage RSMO: Western So East No East Central PUC or DOT State: # FMCSA MC# PUC or DOT State: # DOT# PUC or DOT State: # Other Permits (describe): PROFESSIONAL ASSOCIATIONS or CERTIFICATIONS (Check all that apply) : State Moving or Trucking Association AMSA RIM Tariff Bureau CMC or COIC Designations ISO 2002 Certification IAM State Self Storage Association National Self Storage Association (SSA) PRISM ARMA NAID Other Certifications Other Association or Franchise Memberships: SPECIFIC INFORMATION CARGO COVERAGE Does Applicant issue a Bill of Lading on every shipment? Yes No How many days in the Applicant s standard S.I.T. Period? Other (describe) Is Applicant subject to state regulation or to a Tariff? Yes No Does Applicant regularly use sub-haulers? Yes No What types of cargo paperwork does the Applicant issue? Are contracts or hold-harmless agreements in place for any subhaul Bill of Lading Contract for Move Purchase Order arrangements? If yes, provide a sample of the contract Yes No Master Moving Agreements Freight Bill or Short Form B/L used Other (describe) Does the Applicant supply labor only for on-premises moves? Yes No Does Applicant ever operate as a sub-hauler for any company other than the affiliated Van Line Company? If yes, list companies and type of goods hauled. Yes No When Applicant acts as a sub-hauler, please indicate the contractual charge-back amount: Per Pound: Other: Full Value Replacement Value Other (describe) O 08/12 OPERATIONS SUPPLEMENT Page 1 of 2

27 OPERATIONS SUPPLEMENTAL APPLICATION (Continued) SPECIFIC INFORMATION WAREHOUSE COVERAGE Does Applicant Issue a Warehouse Receipt for all storage? Yes No Does Applicant have Non-Temp Military Storage? Yes No What types of storage paperwork does Applicant issue? Warehouse Receipt Storage Contract Purchase Order Does the Applicant ever have off-site or temporary storage? Yes No Inventory Control Document Bill of Lading Other (describe) Are there any climate controlled storage facilities? Yes No Does Applicant have self-storage or containerized self-storage? Yes No Does Applicant have storage outside of a warehouse building? Yes No Are there any specialized storage services? Yes No Does Applicant hold storage auctions? Yes No Does Applicant store boats or vehicles? Yes No Does Applicant do any specialized crating? Yes No Does Applicant allow customers access to any storage facility? Yes No Describe arrangement of Storage: Vaults Racks Cages or Rooms Loose or un-containerized storage If applicable, how high are vaults stacked? 1-High 2-High 3-High 4-High Other (describe) If yes, describe the kinds of products crated: If yes, Self Storage Units Only All Storage Facilities Are customers supervised? Yes No O 08/12 OPERATIONS SUPPLEMENT Page 2 of 2

28 Supplemental Application for LONG-HAUL TRUCKING OPERATIONS APPLICANT NAME: REQUESTED EFFECTIVE DATE: PLEASE COMPLETE THIS FORM FOR ANY COMMERCIAL USE VEHICLES THAT REGULARLY OPERATE OVER A 300 MILE RADIUS. GENERAL QUESTIONS: 1. Is primary long haul liability coverage provided by the Applicant s Van Line? YES NO 2. What is the percentage of long haul units driven by employees? % 3. What is the percentage of long haul units driven by contractors? % 4. Are driver standards the same for long haul and local operations? YES NO(*) 5. Do any long haul drivers have less than one year over-the-road experience? YES (*) NO 6. Are any long-haul drivers under the age of 23? YES (*) NO 7. Are all owner operators/contractors required to carry Non-Trucking or Bobtail Liability? YES NO(*) 8. Are all owner operators/contractors required to carry Workers Compensation? YES NO(*) 9. Does the contractor s Worker Comp cover his regular and temporary employees? YES NO(*) 10. Is accident or health insurance provided for owner operators/contractors? YES NO(*) ZONE OPERATIONS: Does the Applicant s Long Haul Operation involve a fixed route? YES NO If YES, please indicate the route: If NO, please estimate the percentage of operations in each of the following Zones: (Total should equal 100%) (*) Please provide a detailed explanation of any answer in the remarks section. PACIFIC COAST ZONE (40) California, Oregon, Washington % MOUNTAIN ZONE (41) Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming % MIDWEST ZONE (42) Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin % SOUTHWEST ZONE (43) Arkansas, Oklahoma, Texas % NORTH CENTRAL ZONE (44) Illinois, Indiana, Ohio, Michigan % MID-EAST ZONE (45) Kentucky, Tennessee, West Virginia % GULF ZONE (46) Alabama, Louisiana, Mississippi % SOUTHEAST ZONE (47) Florida, Georgia, North Carolina, South Carolina, Virginia % EASTERN ZONE (48) Delaware, Maryland, New Jersey, New York, Pennsylvania % NEW ENGLAND ZONE (49) Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont % ALASKA ZONE (50) Alaska % NOTE: Generally, all long-haul vehicles will be rated for the same zone, so please indicate on the vehicle schedule if an individual vehicle s operation is different from the breakdown shown above. REMARKS CONCERNING THIS APPLICANT S LONG-HAUL OPERATION: (Use additional space if necessary) LONG HAUL OPERATION INFORMATION L 03/11 PREMIER POLICY APPLICATION LONG HAUL OPERATIONS Page 1 of 1

29 TRANSIT INSURANCE SUPPLEMENTAL APPLICATION DESCRIPTION OF PROGRAM The Transit Insurance Program (TIP) was designed so that policyholders can issue first-party Evidence of Insurance Forms to their customers. The customer then becomes an insured of TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. This coverage is NOT like valuation and should not be shown as such on any Bills of Lading. The premium charged to the customer depends upon the value of property, distance transported, how transported, if SIT coverages is required, and what deductible option is chosen. The basic category rates, however, are unique to each policyholder depending on their individual experience and history. TIP is a separate policy with annual rate review. The policyholder can quote various different coverage options to their customers easily through their program access on the TRANSGUARD website. Once coverage is ordered, the Evidence of Coverage is automatically printed at the policyholder s location. The policyholder collects the premium and transmits to TRANSGUARD at the end of each audit period. PLEASE CHECK WHICH KINDS OF PROPERTY YOUR CUSTOMERS MIGHT WANT TO COVER UNDER THIS PROGRAM: (Show all that may apply-categories can be added during the policy period.) Used Household Goods, Used Home Furnishings and Appliances Any shipments with more than 25% of value in artwork, fine arts or antiques? Yes No Used office or store furniture and furnishings Any shipments with more than 25% of value in computers or electronics? Yes No Artwork, Fine Arts, Statuary, Precious Stones, Musical Instruments, Collections, Antiques Electronics/Computer Hardware, Software and Peripherals Pre-packaged by the manufacturer? Yes No Exhibits, Displays & Theatrical Property New Furniture, Furnishings & Fixtures for offices, stores or restaurants Pre-packaged by the manufacturer? Yes No New Household Furniture & Appliances, Furnishings & Fixtures Pre-packaged by the manufacturer? Yes No Non-hazardous Medical, Hospital & Laboratory Equipment Any shipments with more than 25% of value in electronic or diagnostic equipment? Yes No Motorcycles, Recreational Vehicles, Scooters, Golf Carts and Automobiles Industrial Equipment & Machinery including Printing, Processing and Manufacturing Equipment Not Otherwise Classified (This category will always be included) PLEASE COMPLETE THE FOLLOWING FOR THIS COVERAGE ONLY: Maximum Single Shipment Limit: Aggregate Shipments In Transit Limit: Average Value of Shipments: General Methods of Transportation: 50, , , , , , , ,000 1,000, , , , , , , , ,000 1,000,000 2,000,000 50, , , , ,000 Other Owned Vehicles Contractor Vehicles By Rail or Air By Water Sub-haul or Purchased Transportation Non-Truck/On-Premises Moves Normal Storage-In-Transit Period: 30 days 60 days 90 days 120 Days Estimated Annual Number of Shipments under this policy: Less than More than 36 REMARKS: TRANSIT INSURANCE SUPPLEMENT /11 Page 1 of 1

30 SUB-HAUL/OWNER OPERATORS SUPPLEMENTAL APPLICATION APPLICANT NAME: REQUESTED EFFECTIVE DATE: PLEASE COMPLETE THIS FORM FOR ANY CONTRACTOR/SUB-HAULING OPERATIONS If the answers to any of the following questions change during your policy period, you must notify us within thirty (30) days. GENERAL QUESTIONS: 1. Does Applicant ever operate as a sub-hauler or contractor for any Motor Carrier? YES (*) (*) If YES, Please answer the following additional questions. For which Motor Carriers does applicant sub-haul? Only For my Van Line NO - Go on to question #2 Does Applicant have a written contract or agreement with these Motor Carriers? YES (*) NO (*) If YES, Please attach copies of all of these agreements Which company provides the primary auto liability coverage? Motor Carrier Applicant Which company provides the primary cargo coverage? Motor Carrier Applicant 2. Does Applicant ever directly engage the services of sub-contractors or owneroperators? YES (*) Only through my Van Line Contract NO - Sign & Date form (*) If YES, Please answer the following additional questions. List the Applicant s regular sub-haulers/owner-operators: Does Applicant have a written sub-haul/owner-operator contract with these companies or individuals? (*) If YES, Please attach copies of all of these agreements Which operating authority or Bill of Lading is used for these subcontracted operations? YES (*) Only through my Van Line NO Sub-Contractor Van Line Applicant Are contractor/owner-operator vehicles listed for coverage on the application? YES (*) NO (*) If YES, which coverages are to be provided? Liability & UM Physical Damage (*) If YES, does Applicant need to name contractors or owner-operators as Additional Insureds? Do Applicant s contractors/owner operators have their own primary auto liability coverage? YES YES Through the Van Line Do Applicant s contractors/owner-operators carry bobtail or Non-Trucking Liability? YES (*) NO (*) If YES, where is this coverage written? NAIT Other, list: If contractors/owner-operators are utilized, what is estimated annual payment for their services? (Include the amount paid for all such operations) If the answers to any of the above questions are different for different contractors, please specify on an additional page. NO NO PLEASE NOTE: The Truckers Coverage Form has been withdrawn by the Insurance Services Office (ISO) in most states; TransGuard must now write the Motor Carrier Coverage Form. Coverage provided for owned vehicles is substantially identical in these two forms. However, the Motor Carrier Coverage Form treats contractors or sub-haulers differently from the Truckers Form. If the Applicant does not provide complete and accurate information on their operations as a sub-hauler OR information on the Applicant s use of sub-haulers or owner-operators, there may be unintended gaps in coverage. APPLICANT S SIGNATURE DATE SIGNED PRODUCER S SIGNATURE DATE SIGNED S 07/12 SUB-HAUL SUPPLEMENT Page 1 of 1

31 CLAIMS-MADE GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY JECT LOC AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB CERTIFICATE OF LIABILITY INSURANCE OCCUR OCCUR CLAIMS-MADE MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG EACH OCCURRENCE AGGREGATE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER INSURED THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below CONTACT NAME: PHONE (A/C, No, Ext): ADDRESS: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) WC STATU- TORY LIMITS E.L. EACH ACCIDENT FAX (A/C, No): OTH- ER E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT NAIC # DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

32 CERTIFICATE OF PROPERTY INSURANCE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. If this certificate is being prepared for a party who has an insurable interest in the property, do not use this form. Use ACORD 27 or ACORD 28. PRODUCER INSURED COVERAGES CERTIFICATE NUMBER: CONTACT NAME: PHONE (A/C, No, Ext): ADDRESS: PRODUCER CUSTOMER ID: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : LOCATION OF PREMISES / DESCRIPTION OF PROPERTY (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSURER(S) AFFORDING COVERAGE FAX (A/C, No): REVISION NUMBER: NAIC # THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER COVERED PROPERTY LIMITS DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) PROPERTY CAUSES OF LOSS BASIC BROAD SPECIAL EARTHQUAKE WIND FLOOD INLAND MARINE CAUSES OF LOSS NAMED PERILS CRIME TYPE OF POLICY DEDUCTIBLES BUILDING CONTENTS BOILER & MACHINERY / EQUIPMENT BREAKDOWN TYPE OF POLICY POLICY NUMBER SPECIAL CONDITIONS / OTHER COVERAGES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) BUILDING PERSONAL PROPERTY BUSINESS INCOME EXTRA EXPENSE RENTAL VALUE BLANKET BUILDING BLANKET PERS PROP BLANKET BLDG & PP CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 24 (2009/09) ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

33 DESCRIPTION OF VEHICLE OR EQUIPMENT VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE YEAR MAKE / MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER INSURED CONTACT NAME: PHONE (A/C, No, Ext): ADDRESS: PRODUCER CUSTOMER ID #: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER(S) AFFORDING COVERAGE FAX (A/C, No): NAIC # DESCRIPTION SERIAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR LTR INSR LTR ADD'L INSRD LOSS PAYEE TYPE OF INSURANCE VEH COLLISION LOSS VEH COMP PROPERTY TYPE OF INSURANCE VEHICLE LIABILITY GENERAL LIABILITY OCCURRENCE CLAIMS MADE BASIC SPECIAL VEH OTC BROAD POLICY NUMBER POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YYYY) POLICY EFFECTIVE DATE (MM/DD/YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) POLICY EXPIRATION DATE (MM/DD/YYYY) COMBINED SINGLE LIMIT BODILY INJURY (Per person) PROPERTY DAMAGE ACV ACV ACV RC LIMITS / DEDUCTIBLE AGREED AMT STATED AMT AGREED AMT STATED AMT AGREED AMT STATED AMT LIMITS BODILY INJURY (Per accident) EACH OCCURRENCE GENERAL AGGREGATE LIMIT DED LIMIT DED LIMIT DED REMARKS (INCLUDING SPECIAL CONDITIONS / OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INTEREST Select one of the following: The additional interest described below has been added to the policy(ies) listed herein by policy number(s). A request has been submitted to add the additional interest described below to the policy(ies) listed herein by policy number(s). VEHICLE / EQUIPMENT INTEREST: LEASED FINANCED NAME AND ADDRESS OF ADDITIONAL INTEREST CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DESCRIPTION OF THE ADDITIONAL INTEREST ADDITIONAL INSURED LENDER'S LOSS PAYEE LOAN / LEASE NUMBER LOSS PAYEE AUTHORIZED REPRESENTATIVE ACORD 23 (2010/05) ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

34 COMPANY NUMBER (STATE) COMPANY INSURANCE IDENTIFICATION CARD COMMERCIAL PERSONAL POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER AGENCY/COMPANY ISSUING CARD INSURED SEE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle involved. ACORD 50 (2007/02) ACORD CORPORATION All rights reserved.

35 COMMERCIAL GENERAL LIABILITY /08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED INSURED CONTRACTS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insured: Effective Date: Policy Number: Countersigned by (Authorized Representative) A. WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization (called additional insured) whom you are required to add as an additional insured on this policy under a written insured contract. The written insured contract must be executed prior to the bodily injury, property damage, personal injury or advertising injury. B. The insurance provided to the additional insured is limited as follows: 1. Such person or organization is only an additional insured with respect to liability arising out of: (a) the ownership, maintenance or use of that part of any premises or land rented or leased to you by the additional insured; (b) your work performed for that additional insured; (c) the ownership, maintenance, operation or use by you of equipment leased to you by the additional insured; (d) your work or work performed on your behalf for which any state or political subdivision has issued a permit. 2. Notwithstanding Paragraph 1., the coverage provided to the additional insured by this endorsement does not apply to property damage to personal property that is in the care, custody or control of any insured. 3. The Limits of Insurance applicable to the additional insured are those specified in the insured contract or in the Declarations for this policy, whichever is less. These Limits of Insurance are inclusive and are not in addition to the Limits of Insurance shown in the Declarations. 4. Except when required by the insured contract, the coverage provided to the additional insured by this endorsement does not apply to: (a) bodily injury or property damage occurring after: (1) all work on the project to be performed by you or on behalf of the additional insured has been completed; (2) you cease to be a tenant in the premises which are the subject of the insured contract ; (3) that portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as part of the same project. (b) bodily injury or property damage arising out of the sole negligence of the additional insured. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /08 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

36 COMMERCIAL GENERAL LIABILITY /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION 45 DAY COVERAGE PERIOD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insured: Effective Date: Policy Number: Countersigned by (Authorized Representative) A. WHO IS AN INSURED (Section II) is amended to include the following provision: If the terms of an insured contract require that you name as an additional insured, persons or organizations which are not parties to the insured contract, such person or organization will be considered an additional insured on this policy. The insured contract must be executed prior to the bodily injury, property damage, personal injury or advertising injury. B. The insurance provided to the additional insured is limited as follows: 1. Such person or organization is only an additional insured with respect to liability arising out of: (a) the ownership, maintenance or use of that part of any premises or land rented or leased to you by the additional insured; (b) your work performed for or on the premises of that additional insured; 2. Notwithstanding Paragraph 1., the coverage provided to the additional insured by this endorsement does not apply to property damage to personal property that is in the care, custody or control of any insured. 3. The Limits of Insurance applicable to the additional insured are those specified in the insured contract or in the Declarations for this policy, whichever is less. These Limits of Insurance are inclusive and are not in addition to the Limits of Insurance shown in the Declarations. 4. It is a condition of the coverage granted to the additional insured under this provision that the name and address of such person or organization, as well as a complete description of your work, has been provided to us prior to the commencement of your work for the additional insured. 5. Except when required by the insured contract, the coverage provided to the additional insured by this endorsement does not apply to: (a) bodily injury or property damage occurring after the earliest of the following: (1) all work on the project to be performed by you or on behalf of or on the premises of the additional insured has been completed; (2) that portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as part of the same project; or (3) 45 days after notification as described in Paragraph 4. above. (b) bodily injury or property damage arising out of the sole negligence of the additional insured. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

37 COMMERCIAL AUTO /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Endorsement Effective: Countersigned by: Name of Insured: (Authorized Representative) SCHEDULE Name and Address of Additional Insured: Number of Days Notice: Policy Number: Expiration Date of Policy: A. Who Is An Insured (Section II) is amended to include as an "insured" the person(s) or organization(s) shown in the Schedule, but only with respect to their legal liability for acts or omissions of a person for whom Liability Coverage is afforded under this policy. B. We will mail the additional insured named in the Schedule notice of any cancellation of this policy. If we cancel, we will give 10 days notice to the additional insured unless a longer period is specified in the Schedule. This guarantee will not continue past the expiration of the policy to which this endorsement is attached. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

38 COMMERCIAL GENERAL LIABILITY /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF CANCELLATION PROVISIONS ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insured: Policy Number: In the event of cancellation of insurance afforded by this Coverage Part, we agree to mail prior written notice of cancellation to: SCHEDULE 1. Additional Insured: 2. Address: 3. Number of days advance notice: 4. Effective Date: For any permitted reason, the number of days required for Notice of Cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by any applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. This specific guarantee that we will send Notice of Cancellation to the Additional Insured shown above in the Schedule is only applicable to the work performed for or on the premises of the Additional Insured and will terminate thirty days after such work or such access to premises has ceased or been completed or until the completion of any insured contract with such requirement that Notice of Cancellation be sent. This guarantee will not continue past the expiration of the policy to which this endorsement is attached. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

39 COMMERCIAL UMBRELLA LIABILITY /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF CANCELLATION PROVISIONS ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL LIABILITY UMBRELLA COVERAGE PART This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insured: Policy Number: In the event of cancellation of insurance afforded by this Coverage Part, we agree to mail prior written notice of cancellation to: SCHEDULE 1. Additional Insured: 2. Address: 3. Number of days advance notice: 4. Effective Date: For any permitted reason, the number of days required for Notice of Cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by any applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. This specific guarantee that we will send Notice of Cancellation to the Additional Insured shown above in the Schedule is only applicable to the work performed for or on the premises of the Additional Insured and will terminate thirty days after such work or such access to premises has ceased or been completed or until the completion of any insured contract with such requirement that Notice of Cancellation be sent. This guarantee will not continue past the expiration of the policy to which this endorsement is attached. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

40 INTERLINE /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- VAN LINE This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART Name and address of Van Line Company: SCHEDULE A. Additional Insured In compliance with your duties and obligations as outlined in your contract with the entity shown in the Schedule, the following additional provisions are made a part of this policy: 1. If applicable, the following is added to Truckers Coverage Form CA 00 12, Section II, A. Coverage, 1. Who is an Insured after Paragraph e.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury or property damage caused in whole or in part by your acts or omissions in the performance of your operations conducted under your operating authority or under your Shipping Document. 2. If applicable, the following is added to Motor Carrier Coverage Form CA 00 20, Section II, A. Coverage, 1. Who is an Insured after Paragraph e.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury or property damage caused in whole or in part by your acts or omissions in the performance of your operations conducted under your operating authority or under your Shipping Document. 3. The following is added to Commercial General Liability Coverage Form CG 00 01, Section II Who is an Insured after Paragraph 4.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury, property damage, or personal and advertising injury caused in whole or in part by your acts or omissions in the performance of your operations conducted under your operating authority or under your Shipping Document. 4. The affiliated van line company is an additional insured under the Basic Cargo Liability Coverage Form and Basic Warehouse Liability Coverage Form , but only with respect to liability that results from an occurrence or occurrences that arise out of your operations conducted under your operating authority or under your Shipping Document or Storage Document. B. Notice of Cancellation Unless otherwise specified, we agree to provide the van line company shown in the Schedule with at least thirty (30) days Notice of Cancellation or Non-Renewal; however, we will only provide ten (10) days Notice of Cancellation for non-payment of premium. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 2

41 C. Additional Definitions 1. Shipping Document includes a bill of lading, shipping receipt, freight bill, contract for services issued by you, or a master moving agreement, tariff document, or interline agreement. 2. Storage Document includes a warehouse receipt, storage or space r ental contract, storage receipt, inventory control document, or master storage agreement issued by you. For the purposes of the Coverage Form, Storage Document can also include a bill of lading not issued by you. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 2

42 INTERLINE /11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- VAN LINE OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART Name and address of Van Line Company: SCHEDULE A. Additional Insured In compliance with your duties and obligations as outlined in your contract with the entity shown in the Schedule, the following additional provisions are made a part of this policy: 1. If applicable, the following is added to Truckers Coverage Form CA 00 12, Section II, A. Coverage, 1. Who is an Insured after Paragraph e.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury or property damage caused in whole or in part by your acts or omissions in the performance of your operations. 2. If applicable, the following is added to Motor Carrier Coverage Form CA 00 20, Section II, A. Coverage, 1. Who is an Insured after Paragraph e.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury or property damage caused in whole or in part by your acts or omissions in the performance of your operations. 3. The following is added to Commercial General Liability Coverage Form CG 00 01, Section II Who is an Insured after Paragraph 4.: Your affiliated van line company is included as an insured, but solely with respect to bodily injury, property damage, or personal and advertising injury caused in whole or in part by your acts or omissions in the performance of your operations. 4. With respect to Paragraphs 1. or 2. and 3. above, the insurance afforded to such van line company is primary and we will not seek contribution from any other insurance which such van line company may have available to them. The requirement for this primary status must be a provision of the insured contract between you and the van line company. 5. The affiliated van line company is an additional insured under the Basic Cargo Liability Coverage Form and Basic Warehouse Liability Coverage Form , but only with respect to liability that results from an occurrence or occurrences that arise out of your operations conducted under your operating authority or under your Shipping Document or Storage Document. B. Notice of Cancellation Unless otherwise specified, we agree to provide the van line company shown in the Schedule with at least thirty (30) days Notice of Cancellation or Non-Renewal. However, we will only provide ten (10) days Notice of Cancellation for non-payment of premium. TRANSGUARD INSURANCE COMPANY OF AMERICA, INC /11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

43 Claim #: CLAIMANT S DAMAGE REPORT Please refer to page 2 for Instructions in completing this form. *Date 20 NO LIABILITY IS ASSUMED BY REASON OF THIS REQUEST. *Name of Claimant *Phone (Owner of Property) *Address *City *State *Zip *Address where damage occurred *City *State *Zip *Date damage occurred *Name of COMPANY responsible for damage (if known) Driver s name *Describe damage *Estimated cost of repairs *Describe how damage occurred: Witness Phone Address City State Zip Witness Phone Address City State Zip Amount of cash settlement you will accept for damages ANY ADDITIONAL INFORMATION NOT ADDRESSED ABOVE: FRAUD WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant. NY - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. * I certify that I have read and agree to all fraud warnings contained in this form and that all statements made in this claimant s damage report, and any attached documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. *CLAIMANT S SIGNATURE * Date *CLAIMANT S PRINTED NAME claims.reporting@transguard.com /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 1 of 2

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45 CLAIM #: CLAIMANT S REPORT OF ACCIDENT (AUTO) Please refer to page 4 for Instructions in completing this form. *AGAINST (owner of other auto) *Date: 20 *CLAIMANT S NAME (owner of damaged property) *ADDRESS *Phone # and Street City State Zip code *DESCRIPTION OF YOUR AUTO (This entire section is mandatory.) Make of Car Year Model License # Registered Owner Full Address Name of Driver Age Full Address Do you carry collision insurance on Your vehicle? Check: YES OR NO If Yes what is the name of Your insurance company? Policy / Claim #: Estimated cost of repairs to Your car: Car now at PROPERTY DAMAGED OTHER THAN AUTOMOBILE Describe Property Estimated cost of Repairs of Replacement Location *WAS ANYONE INJURED? YES OR NO *IF YES, THE FOLLOWING IS MANDATORY: Name Address Phone Describe Injuries Medical Treatment Required? YES OR NO If Yes, where Name Address Phone Describe Injuries Medical Treatment Required? YES OR NO If Yes, where *LIST OCCUPANTS OF YOUR AUTOMOBILE (This entire section is mandatory.): Name Address Phone Name Address Phone Name Address Phone *DESCRIPTION OF OTHER AUTOMOBILE (This entire section is mandatory.): Make of Car Year Type/Model License # Driver Address Phone Where there any occupants other than the driver? YES OR NO If Yes, how many? IMPORTANT: LIST WITNESSES NOT IN EITHER AUTOMOBILE INVOLVED: Name Address Phone Name Address Phone Name Address Phone Name Address Phone /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 1 of 4

46 STATEMENT OF ACCIDENT - Please answer every question. *Accident Date 20 *Time *O clock m *Location of accident (street or highway) (At or near cross street or town) *City *County *State Direction you were traveling? What Street? Speed Direction other car was traveling? What Street? Speed Did either driver violate any traffic law? YES OR NO If Yes, which car? Explain If an intersection accident: Speed of each car as it entered the intersection: Your Car Other Car Which car entered the intersection first? Was the view of either driver obstructed? YES OR NO Speed limit at the point of accident Where was the other car when you first saw it? Where was your car at the time? If accident happened at night, did the vehicles have lights on? Your Car: Headlights Tail Lights Brake Lights Other Car Headlights Tail Lights Brake Lights *Weather conditions at the time of the accident (Check all that apply): Wet Dry Fog Rain Snow/Ice Length of skid marks left by your car: Other Car *What did you say at the scene about the accident? *What did the other driver say? *Was there any indication of intoxication? YES OR NO If Yes, in which car? *Date Accident was reported to Police Department *Station / Department City *Either driver Cited or Arrested? YES OR NO *IF YES, THE FOLLOWING IS MANDATORY: Whom? You? Other driver? Charges? Date of Hearing Place Name of Judge *IMPORTANT! : DESCRIBE IN YOUR OWN WORDS HOW THE ACCIDENT OCCURRED: /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 2 of 4

47 *DRAW ROUGH DIAGRAM OF ACCIDENT: Indicate your vehicle as #2 and the other vehicle as #1. Show direction and distance traveled before crash by solid line like so: Then at point of crash. Then positions and distances traveled after the collision using a dotted line *Has your car been repaired? YES OR NO *IF YES or NO, THE FOLLOWING IS MANDATORY: Please attach repair receipt. If NO, then attach estimate of repairs from two well known repair facilities. FRAUD WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant. NY - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. * I certify that I have read and agree to all fraud warnings contained in this form and that all statements made in this claimant s report of accident, and any attached documents are true and correct to the best of my knowledge and belief. No material information has been withheld. *This report must be signed by both the owner and driver of vehicle. *OWNER S SIGNATURE *Date *DRIVER S SIGNATURE *OWNER S PRINTED NAME *DRIVER S PRINTED NAME claims.reporting@transguard.com /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 3 of 4

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52 (OFFICE USE ONLY) CLAIM #: PHYSICAL DAMAGES FIRST REPORT Please refer to page 4 for Instructions in completing this form. Date of Report: *Reported By: *Phone Number: Time Reported: *Relationship to Insured: INSURED INFORMATION: *Name: NAIT Member # or TRANSGUARD Policy # *Address: Apt. #: *City, State, Zip: *Primary Phone #: Secondary Phone #: Fax #: VEHICLE INFORMATION: *Vehicle Year: *Manufacturer: *Model: *Color: VIN #: *Damage to Vehicle: *Current location of vehicle: *Address: *City, State, Zip: Phone #: ACCIDENT INFORMATION: *Date of Accident: *Time: a.m. or p.m. *Location of accident, include street location, city and state: *Detailed Accident Description: /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 1 of 4

53 Were you under dispatch? Yes or No If yes, who was the Motor Carrier? Were you pulling a Trailer? Yes or No If yes, was the Trailer loaded? Yes or No *Did Police Respond? Yes or No *If Yes, What Police Department? Police Report Number: Police Department Phone #: *Were you cited? Yes or No *Was the other party cited? Yes or No *Were there any witnesses: Yes or No *If Yes, fill out information for at least one witness below: *Witness Name: Phone #: Address: City, State and Zip: Witness Name: Phone #: Address: City, State and Zip: *Was another vehicle involved? Yes or No If Yes, please provide the information for the other vehicle(s) below: Other Vehicle #1: Name: Address: City, State, Zip: Phone #: Insurance Company for other Party#1: Phone # for Insurance Company: Policy #: Other Vehicle Information: Year Manufacturer Model Other Party Damages and/or Injuries: Other Vehicle #2: Name: Address: City, State, Zip: Phone #: Insurance Company for other Party# 2: Phone # for Insurance Company: Policy #: /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 2 of 4

54 Other Vehicle Information: Year Manufacturer Model Other Party Damages and/or Injuries: *Were there any additional vehicles involved that are not listed? Yes or No Additional Information that is not addressed above: FRAUD WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant. NY - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. * I certify that I have read and agree to all fraud warnings contained in this form and that all statements made in this Physical Damages First Report, and any attached documents are true and correct to the best of my knowledge and belief. No material information has been withheld. *SIGNATURE *Date *PRINTED NAME claims.reporting@transguard.com /10 TRANSGUARD INSURANCE COMPANY OF AMERICA, INC. Page 3 of 4

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