Motor Truck Cargo Insurance Application

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1 Motor Truck Cargo Insurance Application Named Insured: Mailing Address: Policy period or date policy is to be in effect: Business is: Corporation Partnership Sole Owner Established in 19 For whom does trucker haul primarily? Operates in state of: Common Carrier Private Carrier Contract Carrier With what regulatory commissions are cargo filings made? ICC (include # ) States (include # ) te: If not currently required by regulatory authorities, attach latest year-end statement. Name of present insurance company: Is present policy being cancelled or non-renewed Present insuring conditions: All Risks Named Perils Theft Deductible: Radius of operations (%) Local: % Intermediate % Long Haul: % Page 1 of 5

2 Equipment type Drayage Trucks Tractors Semi-Trailers Full trailers Tank Semi-trailers Refrigerated Trailers Number of Pieces of Equipment Company Owned Long Term Lease Trip Lease From Other Is equipment leased, loaned or rented to others? Does applicant interchange equipment with other carriers? Details: Gross receipts for the past two years: Motor Carrier Freight forwarder Owner Operator Freight Broker Shippers Agent Other Warehousing Total Name principal commodities hauled (avoid term General Commodities ) Does applicant offer insurance coverage to shippers, beyond Bill of Lading? Provide details and annual values: PREMIUMS AND LOSSES Period Losses (Paid and Outstanding) Total From To Prem Fire Collision Overturn Theft Other Page 2 of 5

3 CARGO LIMITS REQUESTED Cargo Limits Requested: per vehicle: per disaster Average exposure per vehicle: Maximum exposure Per vehicle: How long, on average, have drivers been with applicant? Check as appropriate. If you have multiple locations, please attach responses for each location. TERMINALS WHERE VEHICLES MAY BE KEPT attach a copy if required for additional locations Address Construction Protection Limit Does applicant offer insurance coverage to owners, beyond warehouse receipt? Provide details and annual values: Any other entities to be listed as Additional Insureds? Name or Entity Provide details Interest/Activity Page 3 of 5

4 BUILDINGS OR REAL PROPERTY TO BE INSURED attach copy if required for additional locations Address Construction Protection Value GENERAL INFORMATION Explain all YES responses 1. Is there a vehicle maintenance program in operation? If yes, who maintains the vehicles? 9. Are vehicles equipped with anti-theft devices? If yes, 2. Does applicant obtain MVR verification before hiring drivers? 3. Does applicant have a driver recruiting method? 4. Does applicant have a driver training method? If, who trains new drivers? 5. Does applicant have a loss prevention program? If yes, who runs the program? describe 10. Are vehicles left unlocked when unattended? 11. Are any vehicles operated for the applicant by others? 12. Do terminals have fire protection? 13. Do terminals have guards or watchmen? If yes, how many when closed? Guard Watchmen 6. Do drivers receive regular physicals? If, how often? 7. Are drug tests performed at the same time? 8. Are two drivers used on highvalue shipments? 14. Do terminals have alarms, fences, lights or dogs? 15. Are vehicles left loaded overnight? 16. Are loaded vehicles brought home by drivers? 17. Does applicant have a written company personnel policy? Alarm Fences Lights Dogs Page 4 of 5

5 INSURED S WARRANTY I UNDERSTAND THAT THE INFORMATION CONTAINED ON THIS APPLICATION IS CORRECT AND ACCURATE. ANY MATERIAL DISCREPANCIES MAY CAUSE ANY SUBSEQUENTLY ISSUED POLICY TO BE AMENDED OR CANCELLED, AT THE DISCREION OF UNDERWRITERS. Insured s Signature: Agent or Broker: Address: Agent or Broker Signature: Date: Date: Page 5 of 5

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