HAZ MAT SUPPLEMENTAL QUESTIONNAIRE

This form must be completed by the Insured/Applicant in addition to the TRANSPORTATION APPLICATION if the insured hauls hazardous materials or has authority to haul hazardous materials.
SECTION A – GENERAL INFORMATION
1. Insured Name:
2. Do you have the authority to haul hazardous materials? ☍ Yes ☍ No
If “yes”, attach a copy of the authority to this form.
3. Do you haul any substance considered “hazardous waste”? ☍ Yes ☍ No
If “yes”, explain these substances.
4. Do you haul any hazardous materials as defined by the DOT? ☍ Yes ☍ No
Such materials include, but are not limited to: corrosives, explosives, flammable gases, flammable
liquids, flammable solids, hazardous waste, non-flammable gases, oxidizers, poisons, or radioactive
materials.
If “no”, do you agree to notify TIP National, Inc. through your agent prior to accepting any full or
partial loads of hazardous materials or hazardous waste? ☍ Yes ☍ No
Insured/Applicant Signature:
SECTION B – HAZARDOUS OPERATIONS
If you answered “yes” to questions 3 or 4 in Section A. Complete this section.
1. Commodity Information
Hazardous Commodity Description / Hazard Class/Division / UN or NA Number / % of all Commodities Hauled / Full (F), Partial (P), or Bulk (B) Loads / How is the Commodity Packaged?
1)
2)
3)
4)
5)
6)
2. Do you have a hazardous materials training program? ☍ Yes ☍ No
3. Have all employees been certified through the program? ☍ Yes ☍ No
4. Does it include spill prevention and Emergency Response Procedures? ☍ Yes ☍ No
5. Is the training documented? ☍ Yes ☍ No
SECTION C – ROUTE INFORMATION
1. What is the principal route traveled when hauling each hazardous material?(Attach separate sheet if necessary)
FROM / TO
FROM / TO
FROM / TO
SECTION D – SIGNATURES
I attest that the information that I have provided on this form is complete and accurate to the best of my knowledge and belief.
Insured/Applicant Signature: Date:
Agent/Broker Signature: Date:

Edition 7/07