Transportation Division
P.O. Box 8036
Stevens Point, WI 54481-8036
800-610-4888 FAX 715-346-8913 /
TRANSPORTATION - TRUCKING INSURANCE APPLICATION
(FOR ACCOUNTS WITH 10 OR LESS POWER UNITS)
Account Number / Effective DateIndustry Code / Submission Date
Producer Code
Producer
Agency
GENERAL INFORMATION
SUMMARYName
Address Line 1
Address Line 2
City
County / State / Postal Code
Address Type / Authority Type
Phone Number / Fax
Form of Business / Business Description
DOT Number / MC Number / FEIN
ACCOUNT CONTACTS
What is the Contact's Role?
Name
Address Line
City
County / State / Postal Code
Office Phone / Country
Primary E-Mail
Address Type
Attach a separate page if necessary to provide additional information.
LOCATIONSAddress Type
Address Line 1
Address Line 2
City
County / State / Postal Code
Phone Number / # of employees
Primary Location
Check all occupancy descriptions that apply (must check at least one):
GarageOfficeTerminal
Repair/MaintenanceWarehouse
Check all security measures that apply:
LightedFencedDogs
Security AlarmSecurity Guards
Attach a separate page if necessary to provide additional information.
POLICY INFORMATION
OFFERINGS SELECTIONSegment Type:
Selected Lines: / Auto LiabilityAuto Physical DamageGeneral LiabilityInland Marine
POLICY - ADDITIONAL NAMED INSURED
Name:
What is the Relationship to the Primary Named Insured?
Provide the Description of Operations
PRIMARY OWNER / CEO / PRESIDENT
The information provided below may be used to obtain a credit based insurance score determined by information contained in the applicant's credit history which may be used to calculate the quoted premium.
Name
Home Address
City
County / State / Postal Code
Country
Date of Birth / Social Security Number
EXPOSURES
AUTO LIABILITY EXPOSURES
Primary Use / Size Class
Industry Use
Number of Units / Intermediate / Extended / Long Distance
Attach a separate page if necessary to provide additional information.
75-537A 09 12Page 1 of 14
012113
Average Age of Power Units / Number of Trucks (not Truck-Tractors) Pulling TrailersNumber of Truck-Tractors Pulling Double Trailers / Number of Truck-Tractors Pulling Triple Trailers
Furthest State Traveled / Furthest Zone Traveled
PHYSICAL DAMAGE EXPOSURES
Average Age of Power Units
Radius
Value / # of Units / Value / # of Units
Described Power Units / Described Trailers
Undescribed Power Units / Undescribed Trailers
REPORTING BASIS (Not Applicable to Scheduled Unit Policies)
Reporting Method
Gross Receipts - do they include fuel surcharges? / YesNo
ANNUAL ESTIMATES
Reporting Data / Gross Receipts excluding
brokering/subhauling ($) / Mileage / Number of Power Units
Next Year
Current Year
Prior Year
2nd Prior Year
3rd Prior Year
COMMODITIES
Commodity Hauled / % of Total
Loads Hauled / Avg. Load
Values / Max. Load
Values
Attach a separate page if necessary to provide additional information.
COMMODITIES - UNDERWRITING QUESTIONSAutomobiles - Used, Classic, Antique, Auction and Snowbird Type Operations: What percentage of the insured's operations is involved in the transportation of classic, antique, or snowbird vehicles?
Bananas: Does applicant have full authority and a Cargo filing? / Yes No
Calcium Carbide: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Calcium Chloride Solution: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Campers and Recreation Vehicles: What is the average value of the campers/RVs being shipped?
How are the campers/RVs hauled?
Carbon Black: What is the United Nation(s) number for this commodity?
Cement: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Charcoal: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Chicken Sludge/Guts - (Hot Offal), Chicken Fat: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Coal Dust/Powder - Titanium Dioxide: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Corrosive Solids - Salt: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Cotton-Ginned: Is cotton shipped at least 72hours after ginning? / Yes No
Drive/Tow Away Trailers/Tractors: Is the applicant hauling commodities in the trailers? / Yes No
If YES, list commodities hauled
Dry Chemicals: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Edible Oils: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Feed, Seeds: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Fertilizer - Bulk: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Flour: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Fly Ash: Is fly ash the only commodity transported in the tanker? / Yes No
Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Glass Dust/Powder: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Grains: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Lead - Powder - Dust: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Lime - Slacked and Unslacked: Are contents shipped non-bulk? / Yes No
Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Liquid Latex: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Livestock: Do drivers have an average of at least five (5) years experience hauling this commodity? / Yes No
Are race, rodeo, show, and/or competitive horses being transported? / Yes No
Manure/Fertilizer - Bulk: Do manure contents include chicken or bird manure? / Yes No
Are manure contents mixed with any chemicals? / Yes No
Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Milk: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
What is the average length of haul?
Are loads picked up at dairy farms? / Yes No
Molasses: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Mulch/Top Soil or Fill: Is mulch delivered with pesticides, herbicides or other chemicals? / Yes No
Is mulch derived from waste lumber preserved with Chromated Copper Arsenate (CCA)? / Yes No
Oxidizers: Are the trailers gravity feed/bottom discharge? / Yes No
Are the trailers equipped with a pump or vacuum? / Yes No
Are the trailers stainless steel? / Yes No
Paint & Paint Thinners - Canned or Bulk: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Saline Solution: Do contents have an assigned United Nations (UN) or North American(NA) number? / Yes No
If YES, provide the number and a copy of the material safety data sheet
Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Scrap Metal, Iron or Salvage Operation: Are contents hauled in a dump truck or open top van? / Yes No
Where are contents delivered?
Soap - Liquid: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Solar Panels/Cells: What type of module or panel materials are used for cells?
What is the value per module or panel?
Sugar - Liquid: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
Tires - Scrap: Are tires, scrap contents hauled in a dump truck or open top van? / Yes No
Vegetable Oil: Do the drivers have an average of at least one (1) year experience hauling this commodity? / Yes No
Are stainless steel tanks used to haul this commodity? / Yes No
COVERAGE REQUEST
AUTO LIABILITYPOLICY LEVEL
Auto Liability Limit
Auto Liability Deductible / Basket/Occurrence Deductible / Yes No
Hired Auto / Cost of Hire ($)
Non-Owned / Number of employees
Broadened Pollution
Trailer Interchange / Yes No
Limit / Deductible
Radius / Basis
# of Trailers
STATE INFORMATION
These coverages may have statutory options. Please indicate coverage option based on state requirement.
Medical Payments / Yes No
Personal Injury Protection / Yes No
Uninsured Motorist / Yes No
Underinsured Motorist / Yes No
AUTO PHYSICAL DAMAGE
Auto Physical Damage Comprehensive/Collision Deductible
Basket/Occurrence Deductible / Yes No
Downtime Coverage / Yes No
AUTO LIABILITY COVERAGE ADDITIONAL INSUREDS
Blanket Additional Insureds
Freight Broker Shipper Trailer/Container - Liability Operating Rights
Type
Name
Office Phone
Primary E-Mail Address
Address Line 1
City
County / State / Postal Code
Attach a separate page if necessary to provide additional information.
VEHICLESRadius
Intermediate (Other than Zone) Extended Intermediate (Zone) Long Distance (Zone)
Number of Truck-Tractors Pulling Double Trailers
Number of Truck-Tractors Pulling Triple Trailers
Furthest State Traveled / Furthest Zone Traveled
Vehicle Details
Undescribed Trailer / Yes No
Size Class
VIN
Model Year / Make
Ownership
Unit pulls a detachable trailer / Yes No / Year Purchased / (Applicable to 1 Unit New Ventures Only)
Primary Use
Industry Use
Physical Damage / Yes No / Stated Value
Downtime / Yes No
Attach a separate page if necessary to provide additional information.
VEHICLE ADDITIONAL INTERESTS / VEHICLE ADDITIONAL INSUREDSVehicle
Type
Permanently Attached Equipment? / Yes NoIf Yes, Provide Equipment Description
Name
Office Phone
Primary E-Mail Address
Address Line 1
City
County / State / Postal Code
Attach a separate page if necessary to provide additional information.
DRIVERS (Not Applicable to Scheduled Unit Policies)Number of Drivers
New Drivers hired in Last 12 Months
DRIVER DETAILS
Name
Date of Birth / Years of Experience
License Number / License State
Hired Year / Owner Operator / Yes No
Number of moving violations in the past 3 years / Number of at-fault accidents in the past 3 years
Attach a separate page if necessary to provide additional information.
GENERAL LIABILITYPer Occurrence / General Aggregate
Personal Injury / Advertising Liability (same limits as Per Occurrence / General Aggregate)
Medical Expense Damage to Premises Terrorism
Number of GL Units
GENERAL LIABILITY - UNDERWRITING QUESTIONS
Does applicant store/warehouse the goods of others? / Yes No
Does applicant store vehicles of others? / Yes No
Does applicant lease office/warehouse space to others? / Yes No
Does applicant sell or store fuels, chemicals, or other products? / Yes No
Does applicant provide freight forwarding or load consolidation services for others? / Yes No
Does applicant own, rent, or occupy any terminal besides their garaging location? / Yes No
If YES to any of the above questions, explain.
GENERAL LIABILITY ADDITIONAL INSUREDS
Blanket Additional Insureds
Freight Broker Shipper
Type
Name
Office Phone
Primary E-Mail Address
Address Line 1
City
County / State / Postal Code
Attach a separate page if necessary to provide additional information.
CARGOSentry Cargo Group
Coverage Form / Basic Special
Business Description / Trucker Owner Both
Per Vehicle Limit
Cargo Deductible / Basket/Occurrence Deductible / Yes No
Contingent Cargo / Yes No
Terrorism Standard Fire Policy Exception - Terrorism Exclusion (Mutually exclusive with Terrorism)
Number of Cargo Power Units / Average Age of Power Units
Designated Shippers
Designated Shipper
Per Vehicle Limit
Commodity Hauled
% of Total Loads Hauled
Attach a separate page if necessary to provide additional information.
TerminalsTerminal Limit
CARGO - UNDERWRITING QUESTIONS
Are trailers left loaded and unattended in terminals or otherwise during the day? / Yes No
If YES, how many?
Are trailers left loaded and unattended in terminals or otherwise overnight? / Yes No
If YES, how many?
If yes to either question above, provide details of any security precautions taken to secure the vehicle and cargo.
CARGO ADDITIONAL INSUREDS
Blanket Additional Insureds
Freight Broker Shipper Owner of Trailer/Container Freight Forwarder
Type
Name
Office Phone
Primary E-Mail Address
Address Line 1
City
County / State / Postal Code
Attach a separate page if necessary to provide additional information.
UNDERWRITING QUESTIONSGeneral Questions
Number of Years of operation under the authority of the named insured listed?
Number of Years Trucking Management Experience
Is applicant involved in any non-truck business? / Yes No
If YES, explain/provide description of business.
Are any of the applicants' garaging/terminal locations within ten (10) miles of coastal waters? / Yes No
If YES, is there an evacuation plan in place? / Yes No
Number of insurance carriers in the last five (5) years
In the last three (3) years, has applicant been refused, canceled, or non-renewed for Insurance coverage? / Yes No
If YES, explain.
Has applicant operated under a different name and/or US DOT number in the past four (4) years? / Yes No
If YES, explain.
Does applicant transport any hazardous waste, materials or substances? (If YES, Hazardous Material Questionnaire is required) / Yes No
Does applicant haul partial loads? / Yes No
If YES, what percentage of applicant's operations are less-than- truckload?
Do you haul any high valued metals such as copper, aluminum, etc.? / Yes No
If YES, provide details of exposure.
Driver Information
Are passengers allowed to ride in vehicles? / Yes No
If YES, how many passengers per year?
Safety Program
Does applicant have satellite tracking devices? / Yes No
If YES, number of power units with satellite devices
If YES, number of trailers with satellite devices
Does applicant have alarms on vehicles? / Yes No
Does applicant currently use Electronic On-Board Recording (EOBR) equipment to monitor and control hours of service? / Yes No
If YES, what percentage of the applicant's fleet is equipped with EOBR equipment?
Vehicle Information
Indicate the percentage of operations by trailer type (must total 100%)
Auto Hauler
Dry Van
Dump (Backend/Bottom Dump)
Flatbed
Grain
Intermodal Containers/Chassis
Livestock
Lowboy
Refrigerated
Tank
Other Trailer Types
Does applicant transport oversize/overweight cargo? (If YES, Oversize/Overweight Questionnaire is required) / Yes No
Does applicant own/operate tow trucks? / Yes No
If YES, how many?
Does applicant own mobile equipment such as snowplows, forklifts, cranes, cherry pickers, yard goats, etc.? / Yes No
If YES, explain.
Does the applicant have vehicles (power units or semi-trailers) registered in the state of New York, Maryland, Massachusetts or Florida? (If YES, vehicle information is required) / Yes No
Do you loan, lease, or rent tractors or trailers to others? / Yes No
If YES, whatis the frequency?
Brokerage Operations (Not Applicable to Scheduled Unit Policies)
Does applicant broker loads under the same MC / DOT number? / Yes No
If YES, what is the amount of revenue generated by the brokerage operation?
Does the applicant obtain Certificates of Insurance? / Yes No
ADDITIONAL INTEREST - INSURED DESCRIBED VEHICLES
Type
Permanently Attached Equipment? / Yes NoIf Yes, Provide Equipment Description
Name
Office Phone
Primary E-Mail Address
Address Line 1
City
County / State / Postal Code
Vehicle
Stated Value / Ownership
Attach a separate page if necessary to provide additional information.
STATE VEHICLE REPORTINGVehicle Details
Size Class Truck
VIN
Model Year / Make
Registered State
Attach a separate page if necessary to provide additional information.
MOTOR CARRIER INFORMATIONAll owned autos must be insured on this policy to have any filings, certificates, or endorsements on the policy. No filing will be done unless all trucks, tractors, and trailers owned, operated, or used by you are insured with this Company.
Sentry will issue a MCS-90 endorsement and BMC 91X filing with a limit of $750,000 unless requested otherwise and verification is received. The insured can verify the financial responsibility needed by submitting a copy of the form OP-1 Application for Motor Property Carrier and Broker Authority.
The MCS-90 will be issued on all interstate risks and only those intrastate risks requiring it.
The name and address of the Named Insured on the policy must match that of the federal authority granted to the trucker/motor carrier.
Named Insureds
Name
DBA
Address
City
MC Number / MCS-90 only? / Yes No / State / Postal Code
Federal Filings
Form / Name on file with FMCSA / Limit
BMC 91X (Liability)
BMC 34 (Cargo)
State / Province / Liability / Form E MC 65 Cargo / Form H
Oversize/Overweight / Authority / File Number
Name On Filings (if different than Federal)
MC 65
Company Name
DBA
Address Line 1
City
Country / State / Postal Code
Motor Carrier Number (CA)
RISK ANALYSIS
PRIOR LOSS HISTORY
Provide the number of power units the applicant ran each year.
Year / Number of Units / Year / Number of Units / Year / Number of Units
Auto Liability Losses / Current Year / 1st Year Prior / 2nd Year Prior
Amount Paid + Amount in Reserve
Number of Occurrences
Auto Physical Damage Losses / Current Year / 1st Year Prior / 2nd Year Prior
Amount Paid + Amount in Reserve
Number of Occurrences
General Liability Losses / Current Year / 1st Year Prior / 2nd Year Prior
Amount Paid + Amount in Reserve
Number of Occurrences
Inland Marine Losses / Current Year / 1st Year Prior / 2nd Year Prior
Amount Paid + Amount in Reserve
Number of Occurrences
See loss history as provided by applicant and/or agent.