A-One Commercial Insurance Risk Retention Group, Inc. Auto Liability Application GENERAL INFORMATION BILLING OPTIONS. Coverage and Limits Information

Transcription

1 Agency Producer GENERAL INFORMATION Name: DBA (if any): Business Entity: Individual 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: Alt. Phone: BILLING OPTIONS Payments Options: Payment in Full 3 Equal Monthly Installments Financed with GBC Coverage and Limits Information Auto Liability: Combined Single Limits (CSL): $1M CSL $750 CSL Hired Auto: Yes No If yes: Cost of Hire: $ Non-Owned Auto: Yes No If yes #of: Partners: Employees: UM/UIM: Rejected Limits Accepted: $1M CSL $750 CSL Medical Payments: Rejected $5,000 Covered Auto Symbols Auto Liability: UM/UIM: Medical Payments: Covered Symbols: 61- Any Auto 62-Owned Autos Only 63- Owned Private Passenger Type Autos Only 64- Owned Commercial Only 65- Owned Autos Subject to No-Fault 66- Owned Autos Subject to Compulsory UM Law 67- Specifically Described Autos 68- Hired Autos Only 69- Trailers" In Your Possession Under A Written Trailer Or Equipment Interchange Agreement Page 1 of 5

2 Operations Description Carrier Type: Common Contract Private Non-Trucking Other: Radius Percentage of Loads Estimates 0-50 miles Average Radius: miles Longest Radius: 200+ miles Furthest City: Brokered Loads: Yes No If Yes: Percent Outgoing: Percent Incoming: Commodities Commodity Percentage Commodity Percentage Commodity Percentage SCHEDULE OF AUTOS Vehicle Type Vin Number Year Make Gross Weight Check the following that are hauled by applicant: 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. Date of Hire Page 2 of 5

3 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): *if any prior losses please provide hard copy of current loss runs Application Questions Are trucks garaged at multiple locations? Yes No *(If yes above please provide a list of vehicles and their corresponding addresses on next page) Has any policy or coverage been declined, canceled, or non-renewed the past 3 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 Page 3 of 5

4 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 3 years? Yes No Do any drivers have more than 1 moving violation in 3 years? Yes No 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 Do any family members operate any vehicles? (Include on drivers list) Yes No Is any personal use allowed of any company vehicles? Yes No Does applicant hire drivers from driver leasing firms? Yes No Do any employees use their autos in your business? 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. 1 Share priced at $4.00 Share(s) equal to 10% 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: Date: Producer Signature: Date: Page 5 of 5