Liability Applications
(Five Units Or Less)
Fax To 814-255-6010
/Westport
Policies Will Not Be Issued Without SSN/FEIN #
1. Name: / Phone Number:Mailing Address:
Garage Location: / USDOT#: / Date Business Started:
Contact Name:
Applicant is an: Individual Partnership Corporation Joint Venture LLC Other:
2. Type of Motor Carrier: Common Contract Broker MC#: Exempt Private
Type of Carriage: Class 1 Non-Hazardous- $750,000 Class 2 Hazardous- $5,000,000 Class 3 Hazardous-$1,000,000
3. Date Coverage Desired: From: To: New Renewal Rewrite
4. Coverages /
Limits of Liability
Bodily Injury Liability/Property Damage Liability / $CSLHired Car Employer’s Non Ownership / $CSL
Uninsured Underinsured Motorist Liability / $CSL $CSL
Medical Payments Personal Injury Protection / $ Each Person
Specified Causes of Loss Comprehensive / Stated Amount Per SCH $DED.
Collision Combined Deductible / Stated Amount Per SCH $DED.
All Risk Cargo Liability Combined Deductible / $ Per Power Unit $DED.
Other: / $
5. Do you transport any anhydrous ammonia, explosives, gasoline, LPG, acids or chemicals? Yes No
If Yes, explain:
6. Type of Cargo carried and percentage of each: /
Cargo
/ %7. Indicate Zones by showing percentage of long haul operations, over 200 miles, to or from each city group.
Provide mileage pro-rata sheet (Sch’d B)
Zone 1% / Zone 2% / Zone 3% / Zone 4%
Balt. /
Washington
Los Angeles
Miami
New York City
Philadelphia / Atlanta New Orleans
Boston San Francisco
Chicago
Dallas
Hartford
Houston / Buffalo
Charlotte
Cincinnati
Cleveland
Denver
Detroit / Indianapolis
Jacksonville
Kansas City
Little Rock
Louisville
Memphis / Milwaukee/Mnpls.
St. Paul
Nashville
Oklahoma City
Omaha
Phoenix / Pittsburgh
Portland
Richmond
St. Louis
Salt Lake City
San Diego / Remainder of The Country
8. Radius of Operations: 0 to 100 miles% 101 to 300 miles% 301 to 500 miles % Over 500 Miles%
9. Describe the five most common hauls you perform: / 1.
2.
3.
4.
5.
10. Does the applicant ever allow any passengers other than company employees? Yes No
If Yes, Explain:
11. Does the applicant own or operate any equipment over 10,000 GVW other than those listed in this
application or attachments. Yes No
If Yes, Explain:
12. Do you pull double or twin trailers? Yes No If Yes, Percentage of loads:
Do you pull triple trailers? Yes No
13. Is any equipment / a. leased, rented or loaned to others? Yes No
Explain all Yes Answers
b. leased rented or borrowed from others? Yes No
c. interchanged with other carriers? Yes No
14. Do you ever use subhaulers? Yes No
If Yes, how much did you pay to subhaulers in the last 12 months $
15. Name of Present Insurance Carrier, Policy Number and Expiration Date:
16. Do you have your own Workers Compensation Policy or are you covered under any other Workers
Compensation Policy? Yes No
17. In the last three years has any insurance carrier canceled or refused to renew any coverage for which
application is being made? Yes No NOT APPLICABLE IN MISSORI
If Yes, Explain:
18. Loss Experience for the last three years. If there have been no losses enter none, do not leave blank.
Insurance Carrier / From / To / NO of Units /
Losses
Liability / Phys Dam / CargoNO / Amount / NO / Amount / NO / Amount
If loss runs are provided in lieu of the above information, all losses not yet recorded on loss runs but of which the insured has knowledge are to be listed above.
19. Schedule Of Vehicles
Power Units– TT=Tractor ST=Straight Truck HT=Hot Shot TW=Tow Truck SV=Service Vehicle
Unit / Year / Manufacturer / Type / GVW/
CCW / VIN Number / Stated Amount / OTC. DED / COLL DED
TT
TT
Trailers– Body Types- VN=Van RF=Reefer LV=Livestock TN=Tanker PN=Pneumatic CR=Auto
FB=Flat Bed
Unit / Year / Manufacturer / Type / VIN Number / Stated Amount / OTC. DED / COLL DED
VN
VN
20. Cargo Hauled / % / Maximum Value / Average Value / Terminal Coverage
Location:
Terminal Limit: $
Terminal & Yard Fenced? Yes No
24 Hour Supervision? Yes No
Burglar Alarm? Yes No
a. Are all trailers/bodies locked at all times while loaded? Yes No / b. Is each Unit equipped with a fire extinguisher?
Yes No
c. Are loaded vehicles ever left unattended?
Yes No / c. Are vehicles equipped with alarms?
Yes No
e. Are drivers bonded? Yes No / f. Is a standard bill of lading used? Yes No
21. L or A / Unit Numbers / Full Name and Address of Loss Payee (L) or Additional Insured (A)
22. Schedule of Drivers
(Current MVR(s) required or schedule below must be completed in order to obtain a quote)
Driver’s Full Name / State / License Number / Birth Date / EXP / VIO / ACC
23. Is the equipment inspected and maintained in accordance with USDOT requirements? Yes No
If No, Explain:
24. Are all drivers hired and monitored in accordance with USDOT regulations? Yes No
If No, Explain:
States Requiring Intrastate or Exempt Filings Liability Cargo
AK AL AZ AR CA / CO CT FLGAID / IL IN IA KS KY / LA MA MD ME MI / MN MO MS MT NC / ND NE NH NJ NM / NV NY OH OK OR / PA RI SC SD TN / TX UT VA VT WA / WI WV WY CAN
CA EX # / AZ Acct # / IL ID #
Is a USDOT filing required? Yes No Base State for Single State Insurance Regulation:
Notices
Notice to California Applicants
Any person who knowingly presents a false or fraudulent claim for the payment of a loss I guilty of a crime and may be subject to fines and confinement in state prison.Notice to New Jersey Applicants
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.Notice to New York Applicants
Any person who knowingly and the intent to defraud any insurance company or other person files an application for insurance containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crimeAny person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of Insurance Fraud in Third Degree – Class A Misdemeanor, or Second Degree, Class E Felony, or First Degree – Class D Felony.
Notice to Pennsylvania Applicants
Any Person who knowingly and with the intent to injure or defraud, any insurer files an application or claim containing any false, incomplete or misleading information shall upon conviction, be subject to imprisonment for up to seven years any payment of a fine up to$15,000.Notice to Ohio Applicants
Any person who, with the intent to defraud or knowing that he is facilitating to a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud.
Insured Agreements
Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.This applicant agrees to furnish promptly driver data for every driver engaged during the policy period. Applicant, Agent or Broker understand and agree that no flat cancellation will be allowed and either or both guarantee payment of earned premium to final termination date of policy or of any filing made by the company on behalf of the applicant.
In consideration of the premium charged for the policy for which this application is made, and the Company attaching to said policy, either endorsements required by any State Commission or United States Department of Transportation, or both, it is agreed as between the Company and the undersigned that all of the provisions and agreements of the policy shall be in full force and effect in the same manner as if the said endorsement had not been attached. The Named Insured further agrees that the said policy shall not and does not protect the Name Insured against claims for injury, damage or loss sustained by any person when not caused by a motor vehicle specified on said policy, and if the Company shall be obliged to pay any claim it would not be obliged to pay if said endorsements had not been attached, the Insured agrees to reimburse the Company in the amount paid and all sums includes costs and expenses which shall have been paid in connection with such claims.
I, the Applicant, understand the Insurance Producer assisting me with the placement of this Insurance coverage does not have authority to bind coverage. Coverage will be effective only when bound by the Program Manager by telephone, in person, or facsimile.
I hereby declare the foregoing statements to be true to the best of my knowledge and belief, In compliance with Public Law 91-508m this is to inform you that in connection with your recent application for insurance, policy renewal (1) an “investigative consumer report” may be made as to your insurability including, depending on the type of insurance involved, information as to character, general reputation, personal characteristics, mode of living, financial conditions, (2) that such information will be obtained through (but not limited to) personal interviews with friends, neighbors, and associates and (3) upon written request a complete and accurate disclosure of the nature and scope of the “investigative consumer report” will be provided.
Date Signed / Signature of Applicant / Title
Date Signed / Signature of Producing Agents / Signed At
Agency Name: / Address:
Telephone Number: Fax Number:
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