Applicant's Name

Agency Name

Address

Agent

Address

Location

Email

Web Site Address

Phone

Effective Date:

Desired Rate:

1.

How many years has the insured had motor truck cargo insurance in the above name? Years

2.

How many years has the insured been driving truck(s)? Years

Insured Is:

Corporation

Sole Owner

Partnership

Common Carrier

Contract Carrier

Private Carrier

Brokerage

Freight Forwarder

Filings: ICC MC#

Intrastate Authority:

No Yes

Current Carrier:

Has cargo insurance been Canceled/Non Renewed in last 3 years?

No Yes

Does applicant Interchange Equipment with Other Carriers?

No Yes

Trip Lease?

No Yes

Is Equipment Leased, Loaned or Rented to Others?

No Yes

Back Haul?

No Yes

ATTENTION:  PLEASE NOTE THE FOLLOWING:

1.

Quotes cannot be rendered unless this section is complete.

2.

Term General Freight/Merchandise is unacceptable, if % of haul is over 5%.

3.

Average and maximum values are not to reflect policy/contractual limits, but the actual average and maximum values of the loads.

4.

Are commodities owned by Insured?

No Yes

Containerized?

No Yes

SHIPPER

COMMODITY

% HAULED

AVERAGE VALUE

MAXIMUM VALUE

If any of the following are not listed above, they will be specifically excluded from the policy: Alcohol, animals, autos, chemicals, cotton, drugs, eggs, electronic equipment (i.e. computers, cameras, TV's), explosives, hazardous commodities, household goods, jewelry, seafood, tires or tobacco products.

Estimated Gross Receipts for the Coming Year:

$

Gross Receipts for Past Years:

From:

To:

Gross Receipts $

From:

To:

Gross Receipts $

From:

To:

Gross Receipts $

Number & Pieces of Equipment

Company Owned

Owner Operators

Long Term Lease

Trucks

Tractors

Trailers: Flatbed  Boxed

Refrigerated

Terminal Coverage (Complete Only If Requesting Coverage)

Street

City & State

Construction

Security

Limit

Radius of Operation:

% Local

% Intermediate

% Long Haul

(0-200 miles)

(201-499 miles)

(over 500 miles)

Loss History:  Please complete ("See Attached" is unacceptable)

Premium

Fire/Overturn/Collision/Theft/Other

Reserve

Amount Paid

The following underwriting information is requested by the companies and must be submitted on all bound accounts:

*Three (3) years company loss runs, signed application (new business only), current MVR's within thirty (30) days of inception, *current financial statement (if filings are required), schedule of vehicles w/vin numbers (per unit policy only) and *maintenance and safety programs (new business only).

For policies with ten (10) or less units, a statement for the above items with a * may be sent for the insured's signature in lieu of actual documents.

2.  Hit this Submit button.