A-One Commercial Insurance Risk Retention Group, Inc. Auto Liability Application GENERAL INFORMATION

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1 Agency Producer Name: DBA (if any): GENERAL INFORMATION Business Entity: Individual Sole Proprietor Corporation Partnership LLC Other: Effective Date: US DOT: SSN or FEIN: Yrs in business: Yrs in Trucking Industry: MC #: Mailing Address: City: State: Zip: Garaging Address: City: State: Zip: Contact: Phone: List Filling(s) Required: Payments Options: Payment in Full Financed with GBC Coverage and Limits Information Auto Liability: Combined Single Limits (CSL): $M CSL $750 CSL Medical Payments: Rejected $5,000 UM/UIM: Rejected Limits Accepted: $5/0 $0/60 $M CSL $750 CSL Deductible: $500 $,000 Other: *A Deductible of $500 is standard on A-One s Auto Liability coverage. Operations Description Radius Percentage of Loads Estimates 0-50 miles Average Radius: miles Longest Radius: 00+ miles Furthest City: Carrier Type Common Contract Private Non-Trucking % of Business (Should Equal 00%) % % % % Brokered Loads* % *Brokered Loads : Any load or haul carried which is outside of the insured s regularly held contracts Breakdown of Brokered Loads: Percent Outgoing % Percent Incoming % Other % Commodities Commodity Percentage Commodity Percentage Commodity Percentage Page of 5

2 Vehicle Type (Truck, Tractor, Trailer) Check the following that are hauled by applicant: SCHEDULE OF AUTOS Vin Number Year Make Gross Weight Longest oneway trip (miles) City Destination of longest haul Single Trailer Double Trailer Triple Trailer Oversized/Overweight Vehicles Other: DRIVER INFORMATION Name D.O.B State License # Permit # Years of Class A Exp. Insurance History For Past Three Years Policy Period (MM/YY) Company Name Liability Losses Physical Damage Losses Number Amount Number Amount Please check here if no losses Loss Description(s): Date of Hire *if any prior losses please provide hard copy of current loss runs Page of 5

3 Application Questions Are trucks garaged principally at multiple locations? Yes No *(If yes above please provide a list of the locations and vehicles that are principally garaged at each below) Garaging Address (Street, Sate, Zip) Last 6 Numbers of VINs at location (Separate my commas) Has any policy or coverage been declined, canceled, or non-renewed the past years? Yes No Does applicant haul any dangerous, caustic, radioactive or flammable cargo? Yes No Do you haul commodities that are subject to tight delivery time constraints? Yes No Does applicant transport passengers? Yes No Does applicant own any cargo being transported? Yes No Does the applicant broker loads out to others? Yes No Are all vehicles listed owned and registered to applicant? Yes No Any vehicles titled to an individual instead of business? If yes, Provide details. Yes No Are any owned vehicles not listed on this Application? Yes No Does applicant have a vehicle maintenance program? Yes No Are re-treads used on power units or trailers? Yes No Does applicant obtain MVRs at time of hire? Yes No How often are MVRs reviewed? Do drivers perform a road test at time of hire? Yes No Are drivers required to pass a drug test at time of hire? Yes No Do drivers complete a written application at time of hire? Yes No Any drivers with an accident, regardless of fault, in the past years? Yes No Do any drivers have more than moving violation in years? Yes No Page of 5

4 Do you have regularly scheduled safety meetings? Yes No Is a formal training program in place or utilized? Yes No Are Drivers provided set routes for more than 75% of runs? Yes No Do drivers have mounted GPS? Yes No Are any drivers not covered by Workers Comp? Yes No Does applicant hire drivers from driver leasing firms? Yes No Do you use any volunteers? Yes No Please provide any explanations for answers or information requested below: Copy of Driver MVRs Schedule of Requested Attachments for Auto Liability Three Year Currently Valued Loss Run from Prior Carrier (within last 60 days) Page 4 of 5

5 Share Purchase Agreement As an insured with A-One Commercial Insurance, RRG you have the opportunity to be a shareholder as well as an insured member. Due to the formation of A-One as a Risk Retention Group you will be required to purchase a share of the company which will allow you to be a voting shareholder in the company. Shares will be repurchased by the RRG upon termination of coverage, subject to Tennessee Department of Insurance Approval. We will offer two share purchase methods. Please select one of the below options. Share priced at $4.00 Share(s) equal to 0% of premium(s). The statements and answers given on this application are true and accurate. The applicant has not willfully concealed or misrepresented any material fact or circumstance concerning this application. Applicants Name: Title: Applicants Signature I understand that checking this box constitutes a legal signature. Date: Producer Signature I understand that checking this box constitutes a legal signature. Date: Page 5 of 5

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