COURIER PROGRAM APPLICATION
The program offers Scheduled Auto and Non-Owned Auto (for Independent Contractors [ICs] & Employees who drive their own vehicles to make deliveries), General Liability/Property Package and Cargo Coverage. We cannot offer stand-alone coverage – we will need to write the auto with, at least, one supporting line of business. For quicker submission turn-around, please complete the application in its entirety (pages 1 – 6) with no blanks(using N/A for those that do not apply) along with any applicable supplemental applications (located within this document.)
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Requested Coverage: Auto Liability with GL/Prop Auto Liability with Cargo Auto Liability with GL/Prop & Cargo
Auto Liability Submission ChecklistCompleted Apollo Courier Program Application
Completed ACORD Applications
Complete Description of all entities
Five Year Currently Valued Loss Runs, within 90 days of the
effective date of coverage
Drivers List including: Name, Date of Birth, Drivers License
Number & State Licensed in
Motor Vehicle Records (MVR’s) – with print date of at least
60 days prior to the effective date of coverage
Vehicle Schedule (for Owned/Scheduled Units, if any) to
include Year/Make/Model, complete VIN, Radius, Class
Code, Garaging Location & Cost New
Copy of the standard Independent Contractor Agreement,
if utilizing ICs
Last Five Year Auto Premiums for loss ratio
Index page of the Safety Manual
Most current annual financials (Income Statement & Balance Sheet) / GL/Property Package Submission Checklist
Completed ACORD 125 and GL ACORD 126
Completed ACORD 140 (with all COPE Information)
Five Year Currently Valued Loss Runs, within 90 days of
the effective date
Last Five Year GL and Property Premiums for loss ratio
Cargo Submission Checklist
Completed ACORD 125 and ACORD 143
MVR’s – with print date of 60 days
Five Year Currently Valued Loss Runs, within 90 days of
the effective date
Last Five Year Cargo Premiums for loss ratio
Business Name: / Eff. Date:
Street/City/State:
All DBA Names:
Complete Description of Operations per Entity:
Date Business Started (mo/yr): / Website:
If in business less than 3 years, we must receive an outline of prior courier experience (Please attach)
Contact Person: / Title:
Phone Number: / E-mail: / FEIN:
Are you a Member of a National Association? / Yes No / If yes, please list:
Gross Revenue Last Year: / Anticipated Gross Revenue This Year:
Has any insurance been cancelled or non-renewed in the last 3 years? / Yes No
If yes, please explain:
GENERAL AUTO QUESTIONS - SECTION A
Driving Radius: / 50 miles: / % / 51-100 miles: / % / 101-200 miles: / % / 200 miles: / %
Maximum Distance Traveled: / Description of Operations over 200 Miles:
Largest Cities Entered:
Filing Requirements: / N/A / DMV / BMC-91X / Form E / Other:
Filing Numbers: / CA #: / DOT #: / MC #: / FF #:
Types of Commodities Delivered:
Do your services include assembling, installation or package removal? / Yes No
If Yes, please describe:
Major Clients:
Are Hazardous Commodities Delivered? / Yes No / If Yes,complete the Hazardous Supplemental App.
Are Pharmaceuticals Delivered? / Yes No / If Yes,complete the Pharmaceutical Supplemental App.
Are Medical Specimens Delivered? / Yes No / If Yes,complete the Medical Specimen Supplemental App.
Are STAT Deliveries Guaranteed 1 hr? / Yes No / If Yes,complete the STAT Delivery Supplemental App.
Are Electronics Delivered (other than parts)? / Yes No / If Yes,complete the Electronic Delivery Supplemental App.
Percentage of Operations Commercial Delivery: / % / Percentage of Operations Residential Delivery: / %
Regarding Residential Deliveries, are drivers allowed to enter the customer’s home? / Yes No
Hours of Operations: / # of Shifts/Hours:
Are employees or passengers transported in company vehicles? / Yes No
If Yes,please explain:
Do you participate in a Department of Motor Vehicle MVR “Pull Program” (CA only)? / Yes No
Are there appearance and dress code requirements for Drivers? (e.g., uniforms): / Yes No
Are vehicles leased to or from others? / Yes No
Do you do contract handling for others? / Yes No
If Yes,please provide details:
Do Applicant Drivers drive customer’s vehicles? / Yes No
If Yes,please provide details:
OWNED / SCHEDULED AUTO QUESTIONS - SECTION B
# of Owned Vehicles: / # of Long Term Lease Scheduled Auto: / Total # of Scheduled Units:
Are there any Owned/Scheduled Truck Tractors (45k GVW or more) Utilized? / Yes No
If Yes,please complete the Truck Tractor Supplemental Application
Do you provide a safe garaging area for Owned Vehicles? / Yes No
Is lot fenced and lit? / Yes No
Are any vehicles owned or leased by your company NOT on this schedule? / Yes No
Are any scheduled vehicles registered to individuals and not used in the business? / Yes No
Are any Owned/Long Term Leased vehicles kept at driver’s homes? / Yes No
Is Personal Use of Company Owned Vehicles Permitted? / Yes No
Are family members permitted to drive insured vehicles? / Yes No
If Yes,Which vehicle(s) and who are they titled to and used by?
NON-OWNED AUTO QUESTIONS - SECTION C
Do you lease drivers from a Professional Employee or Independent Contractor Organization? / Yes No
If Yes, Please provide the Name of Organization:
If Yes, Please provide a copy of the contract
Do you Utilize Independent Contractors for your Deliveries? / Yes No
If Yes, Please complete the Independent Contractors area of this Application (Pg. #3)
Do you Utilize Employees who drive their own vehicles to make Deliveries? / Yes No
If Yes, Please complete the Employees Who Drive their Own Vehicles area of this Application (Pg. #3)
INDEPENDENT CONTRACTORS MAKING DELIVERIES UTILIZING THEIR OWN VEHICLES N/A
Total # of ICs: / What is the Total AnticipatedAmount Paid these Drivers (Combined) for the Year?
Type of Vehicles:
Number of: / Private Passenger / Light Trucks/Vans / Med. Trucks/Vans
Heavy Trucks/Vans / * X Heavy Truck Tractors (45k GVW or more)
* If you utilize ICs who drive Truck Tractors (45K GVW or more), please complete the Truck TractorsApplication
Do you have an Independent Contractors agreement in place? (please provide a copy of the contract) / Yes No
Do you keep copies of Independent Contractors individual Auto Insurance Dec. pages on file? / Yes No
Do you require ICs to have a CommercialAuto Policy in force? / Yes No
If No, Do you require Personal Lines Auto Policies contain a “Business Use Endorsement”? / Yes No
Do you obtain Additional Insured/Indemnification Clause Certificates of Insurance from the Driver policies? / Yes No
What is the Underlying Insurance Requirement for ICs?
State Min. / $25K / $50k / $100k / $300k / $500k / Other:
EMPLOYEES WHO DRIVE THEIR OWN VEHICLES WHILE MAKING DELIVERIES N/A
# of Empl.: / What is the Total AnticipatedAmount Paid these Drivers (Combined) for the Year?
Type of Vehicles:
Number of: / Private Passenger / Light Trucks/Vans / Med. Trucks/Vans
Heavy Trucks/Vans / * X Heavy Truck Tractors
* If you utilize employees who drive Truck Tractors (45K GVW or more), please complete the Truck TractorsApplication
Do you have a written agreement in place for these drivers? (please provide a copy of the agreement) / Yes No
Do you require Employee Drivers to have a Commercial Auto Policy in force? / Yes No
If No, Do you require Personal Lines Auto Policies contain a “Business Use Endorsement”? / Yes No
Do you keep current copies of all these employees Auto Dec. Pages on File? / Yes No
You obtain Additional Insured/Indemnification Clause Certificates of Insurance from the Driver policies? / Yes No
What is the Underlying Insurance Requirement for these Employees?
State Min. / $25K / $50k / $100k / $300k / $500k / Other:
DRIVER RELATED QUESTIONS - SECTION D
Do Drivers operate the same vehicle each day? / Yes No
Are there periodic physical exams for drivers? / Yes No
If Yes, what is the frequency of the exams?
Do you require at least three years driving experience in U.S.? / Yes No
Do you allow Drivers under the age of 21? / Yes No
Are any drivers over the age of 75? / Yes No
What is the annual percentage of driver turnover? / %
How are Drivers Paid? (Hourly, Salary, Commission, per Route):
Do drivers load or unload vehicles? / Yes No
Do drivers use cell phones or radios while making deliveries? / Yes No
Is a “hands free” only cell phone policy in place while driving? / Yes No
Do driver job specifications include a driving experience level? / Yes No
Must applicants complete a written application? / Yes No
Is proof of Legal Residency a part of the application? / Yes No
Are MVRS checked prior to hire and annually thereafter? / Yes No
Are applicants interviewed by Management? / Yes No
Must applicants complete a road test? / Yes No
Must applicants complete a written test? / Yes No
Do you have a drug test policy or program? / Yes No
If Yes,is drug testing at hire and randomly thereafter? / Yes No
Do you perform background checks prior to hiring? / Yes No
Are references checked? / Yes No
Is there safety incentive program in place? / Yes No
Is driver training provided? / Yes No
If Yes,what is the frequency of Training?
SAFETY QUESTIONS - SECTION E
Do you have a formal Safety Program? / Yes No
If Yes,please describe:
Do you hold Driver Safety Meetings? / Yes No
If Yes,how often?
Do you have a full-time Safety Manager/Coordinator/Risk Manager? / Yes No
Are there regular vehicle inspections? / Yes No
If Yes,how is it documented?
Do you have a vehicle Maintenance Program? / Yes No
If Yes,how is it documented?
Are maintenance files kept for all vehicles? / Yes No
Is there a formal Accident Review Committee? / Yes No
Do you utilize an Accident Register? / Yes No
Are accident records and files maintained? / Yes No
Are drivers drug tested immediately after an accident? / Yes No
Are Vehicles Equipped with any of the following:
Collision Avoidance Systems / Yes No
Intelligent Parking Assist Systems / Yes No
Rollover Detection and Monitoring Systems / Yes No
Lane Tracking Devices / Yes No
Vehicle and/or Cargo Tracking System (e.g., GPS) / Yes No
GENERAL LIABILITY/PROPERTY QUESTIONS - SECTION F
Please provide the total number of employees:
Are there more than 50 employees at one location? / Yes No
Are sidewalks, walkways, stairways and parking lots maintained? / Yes No
Do receipts from service, repair or installation exceed 25% of total revenue? / Yes No
Regarding building maintenance, Are Contractors required to have $1mm in coverage and name the Business Owner as Additional Insured? / Yes No
Is the Owner on premise 75% or more during business hours? / Yes No
Do your operations include a Warehouse (storage for others)?
Please note: If your operations include Warehouse, a separate Warehouse Legal Liability Policy is needed in order to consider writing the General Liability. / Yes No
Please provide the total number of insured locations:
Please indicate the following for each location:
Location # 1 – Street/City/ZIP:
Description of Operations:
Location # 2 – Street/City/ZIP:
Description of Operations:
Location # 3 – Street/City/ZIP:
Description of Operations:
Location # 4 – Street/City/ZIP:
Description of Operations:
(Attach a separate sheet for additional locations) / Location #1 / Location #2 / Location #3 / Location #4
Is there a Central Burglar Alarm? / Yes No / Yes No / Yes No / Yes No
Is there a Locally Stationed Burglar Alarm? / Yes No / Yes No / Yes No / Yes No
Is there a Central Fire Alarm? / Yes No / Yes No / Yes No / Yes No
Is there a Locally Stationed Fire Alarm? / Yes No / Yes No / Yes No / Yes No
What percentage of the building is Sprinklered? / % / % / % / %
Are there Security Protections in place?
(set alarms, deadbolts, cash placed in safe etc.) / Yes No / Yes No / Yes No / Yes No
Are there surge protector equipment? / Yes No / Yes No / Yes No / Yes No
Is the building air-conditioned? / Yes No / Yes No / Yes No / Yes No
Is the building designed for the current occupancy? / Yes No / Yes No / Yes No / Yes No
What is the square footage of the occupied space?
Please provide the number of stories/floors:
How many elevators are there?
Do buildings have two or more exits on each floor? / Yes No / Yes No / Yes No / Yes No
Do buildings have barred windows? / Yes No / Yes No / Yes No / Yes No
If Yes, are there safety releases? / Yes No / Yes No / Yes No / Yes No
Any there any other building occupancies? / Yes No / Yes No / Yes No / Yes No
If Yes, please describe:
Are there any gas pumps or underground tanks? / Yes No / Yes No / Yes No / Yes No
Are there any used items sold? / Yes No / Yes No / Yes No / Yes No
Any business open after 11:00 pm? / Yes No / Yes No / Yes No / Yes No
Any buildings vacant more than 60 days? / Yes No / Yes No / Yes No / Yes No
What is the construction type of the building?
What is the roof type of the building?
Please provide the year built for each building:
IfBuildings are 30 years old or older, please provide:
Year the Wiring was last updated:
Year the Heating was last updated:
Year the Plumbing was last updated:
Year the Roofing was last updated:
CARGO QUESTIONS - SECTION G
Detailed description of commodities:
What is the average value of cargo per anyone vehicle?
What is the maximum value of cargo per anyone vehicle?
Is Document Reconstruction Coverage Needed? / Yes No
If Yes,Please provide the cost of Reconstruction (Limit):
Are Independent Contractors (ICs) required to carry their own Cargo limit, per contract? / Yes No
If Yes,Please provide the required limit:
If Yes, Are you seeking Cargo Coverage above the ICs Cargo Limit? / Yes No
If Yes,Please provide the limit you would like quoted:
If Special Limits for Cargo are needed, per individual contract(s) , please provide the below information for each contract
(using a separate sheet if necessary):
Customer Name: / Limit Required:
Types of Commodities:
Annual Revenue for this contract: / Average Radius: / Max. Radius:
Customer Name: / Limit Required:
Types of Commodities:
Annual Revenue for this contract: / Average Radius: / Max. Radius:
Customer Name: / Limit Required:
Types of Commodities:
Annual Revenue for this contract: / Average Radius: / Max. Radius:
APPLICANT SIGNATURE - SECTION H
Note: Certain States have statutes concerning fraudulent claims and/or deliberate misrepresentations to induce an insurer to provide coverage. If you wish to know the ramifications of such acts in your State, please consult with your insurance agent.
Note: The proposed insurance company reserves the right to inspect your operations, while it has no duty to do so. Should an inspection be conducted that generates recommendations to an insured, failure to comply may result in the cancellation of the policy.
I hereby certify that the foregoing information supplied on this application, along with any supplemental information provided in connection thereto, is true and accurate to the best of my knowledge. I further understand that any policy issued to me was done so upon reliance of the representation herein. I further understand and agree that any intentional material misrepresentations could compromise the insurance protection hereby afforded.
Printed Name of Applicant / Title
Signature of Applicant / Date
Courier Program Application 06/15 1 of 6
COURIER PROGRAM SUPPLEMENTAL APPLICATION
STAT DELIVERIES
This supplemental accompanies the completed Courier Program Application
Please complete this supplemental only if your business operations include STAT Deliveries
(Guaranteed under 1 hour time frame)
Business Name:What percentage of the total operations is considered STAT Delivery (guaranteed 1 hour time frame)?
Approx how many STAT deliveries are done on average per day and per week? / Per day: / Per week:
What is the maximum radius for these types of deliveries?
Is there more than one STAT delivery made at any one time?
What is the largest city entered for STAT deliveries?
How often (percentage) do they enter a large city to deliver on a STAT basis?
Please provide a detailed list of the types of commodities delivered on a STAT basis:
Are there driver consequences if a delivery is not made within an hour? / Yes No
If Yes,what are they?
Are the consequences outlined within a written agreement? / Yes No
Please provide an outline of the safety procedures for these type of deliveries:
Please forward a copy of the contract(s) between the business owner and the driver, outlining the STAT delivery requirements and/or consequences.
APPLICANT SIGNATURENote: Certain States have statutes concerning fraudulent claims and/or deliberate misrepresentations to induce an insurer to provide coverage. If you wish to know the ramifications of such acts in your State, please consult with your insurance agent.
Note: The proposed insurance company reserves the right to inspect your operations, while it has no duty to do so. Should an inspection be conducted that generates recommendations to an insured, failure to comply may result in the cancellation of the policy.
I hereby certify that the foregoing information supplied on this application, along with any supplemental information provided in connection thereto, is true and accurate to the best of my knowledge. I further understand that any policy issued to me was done so upon reliance of the representation herein. I further understand and agree that any intentional material misrepresentations could compromise the insurance protection hereby afforded.
Printed Name of Applicant / Title
Signature of Applicant / Date
Courier Program Supplemental (STAT) 06/15 1 of 1
COURIER PROGRAM SUPPLEMENTAL APPLICATION
PHARMACEUTICAL DELIVERIES
This supplemental accompanies the completed Courier Program Application
Please complete this supplemental only if your business operations include Pharmaceutical Deliveries
(Classified as Narcotics)
Business Name:Please provide a detailed list of the types of pharmaceuticals that are being delivered in the following Schedules
(as defined by the U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control)
Schedule I (CI) Substances:
Schedule II (CII) Substances:
Schedule III (CIII) Substances:
Schedule IV (CIV) Substances:
Schedule V (CV) Substances:
What percentage of the total operations makes up pharmaceutical deliveries?
Please provide the percentage of Business vs. Residential for these deliveries: / Business: / Residential:
Are they scheduled or routed deliveries? / Yes No
Are Pharmaceuticals delivered in a mixed load (delivered with other commodities)? / Yes No
If Yes,what is the average percentage represents pharmaceutical per each load?
Are pharmaceuticals kept in a sealed, locked, tamper-resistant receptacle? / Yes No
Is the delivery vehicle ever left unattended? / Yes No
Are all vehicles making pharmaceutical deliveries equipped with GPS? / Yes No
Are all vehicles making pharmaceutical deliveries equipped with Security Alarms? / Yes No
Is the delivery vehicle, that contains Narcotics, driven from Point A to Point B, only, with no stops? / Yes No
Do delivery vehicles contain pharmaceutical delivery signage? / Yes No
Please provide a detailed outline of the security measures put in place for the drivers of these types of deliveries:
APPLICANT SIGNATURE
Note: Certain States have statutes concerning fraudulent claims and/or deliberate misrepresentations to induce an insurer to provide coverage. If you wish to know the ramifications of such acts in your State, please consult with your insurance agent.
Note: The proposed insurance company reserves the right to inspect your operations, while it has no duty to do so. Should an inspection be conducted that generates recommendations to an insured, failure to comply may result in the cancellation of the policy.
I hereby certify that the foregoing information supplied on this application, along with any supplemental information provided in connection thereto, is true and accurate to the best of my knowledge. I further understand that any policy issued to me was done so upon reliance of the representation herein. I further understand and agree that any intentional material misrepresentations could compromise the insurance protection hereby afforded.
Printed Name of Applicant / Title
Signature of Applicant / Date
Courier Program Supplemental (Pharmaceutical) 06/15 1 of 1