TIP National, LLC
1900 NW Expressway
Suite 860
Oklahoma City, OK 73118
Phone: 405.848.8888
Fax: 405.848.8891
Fleet: ______City, State: ______
Expiration Date: ______Proposed Effective Date: ______Date Quote Required: ______
Agency: ______Producer(s): ______Address: ______
CSR’s: ______
Are you the incumbent broker? ☍ Yes ☍ No Phone: ( ) ______
If yes, for how long? ______( 800 ) ______
Fax: ( ) ______
To underwrite this application, all sections of the application must be completed, no omissions, and no see attached, must be signed by an officer of the applicant and a TIP National producer. No brokered business will be considered:
_____1. Financial Statements: Balance sheets and income statements for the last 2 years and a
current interim statement (if the most recent year-end statements are more than 6 months
old) are required. We prefer audited or reviewed statements, if available. Statements
should include revenue obtained through trip lease and brokerage operations. Parent
company financials, if applicable, should be provided.
_____2. Loss Runs: Provide documented loss experience, valued within the past 90 days (we
prefer valued within the last 60 days), from prior insurers for all lines of coverage
requested for the current year and prior 4 years. Provide details on all losses in excess of
$50,000. Provide summary of losses as required in this application.
_____3. Mileage: Provide fuel tax reports, indicating mileage by state and total mileage for all
states for the previous 8 calendar quarters. Indicate any mileage which may not be
included on fuel tax reports. Record mileage summaries and projections on this
application.
_____4. Revenue: Record revenue history and projections in this application. If any revenue is to
be excluded for reporting purposes, make sure your underwriter approves and deletes from
historical and projected.
_____5. Equipment Schedule: Attach current listing of all company owned and owner/operator
vehicles, including year, make, model, VIN, current market value, where garaged and
licensed. For local/intermediate operations, (up to 200 mile radius), included gross
vehicle weight for each unit for rating purposes.
_____6. Drivers List: Attach listing of all drivers operating equipment to be covered by
Insurance: company drivers, owner/operators, drivers of service and private passenger
units. List should include full name of driver, date of birth, state of license issued,
driver’s license number, date of hire and years of experience. Copies of the most recent
motor vehicle reports(MVRs) on file with the applicant are requested for all drivers. TIP
National minimum score 80%.
_____7. Agreements: Provide copies of all applicable agreements used by applicant, including
permanent lease, trip lease, hold-harmless, interline, interchange, intermodal, and
sub-hauler agreements.
_____8. Safety Materials: Attach copy of most recent state or federal compliance review and
current compliance rating document. Provide copies of pertinent fleet safety and
maintenance programs and materials.
_____9. DOT Rating: Provide most recent DOT inspection with rating.
_____10. Terminals: Furnish complete address and details of security at each terminal. Also list
of vehicles broken down by terminal.
_____11. General Liability: Attach ACORD application with GL payroll excluding drivers and
clerical. GL history with prior 5 years of currently valued insurance company loss runs.
_____12. Operating Permit(s): Attach copies of all permits in the name of applicant(s) to be
considered for insurance in this application.
_____13. Producer License for State that Insured’s Business is Garaged in.
Page 1 of 2 Rev. 9/2014