4.
Number of years Applicant has owned a
similar type of vehicle
5.
Number of years Applicant has driven a
similar type of
vehicle?
6.
Number of years Applicant has driven a
similar radius?
7.
Percent of trips in each radius (one way
mileage):
*NOTE
: Sum of Canada plus U.S. must equal 100%
Canada
50 miles
100 miles
300 miles
900 miles
Over
U.S.
50 miles
100 miles
300 miles
900 miles
Over
8.
What major cities in Canada and the
United States does the
Applicant operate in or through?
(Within a 25 mile radius of a city
centre)? XXXX (checkbox or
text box?)
9. Based
on total annual mileage, what percentage
is driven in
each State/Province? See Enclosed
10.
Which States/Provinces will the
Applicant operate in or
through? See Enclosed Mileage Report
11.
FILING NUMBER'S
CVOR:
RIN:
ICC:
SSR:
Any special
filings needed:
12.
Does the Applicant own or leave and US
domiciled
vehicles? If yes, please provide further
info
If yes,
please provide further info
No
Yes
(Further Info:)
13.
Does the Applicant own or leave and US
domiciled
vehicles?
If yes,
please provide further info
No
Yes
(Further Info:)
14.
Does the Applicant own or lease any
vehicle other than
those listed?
If yes,
provide further info
No
Yes
(Further Info:
)
15.
Does the Application lease, loan or rent
any of his vehicles
to others?
If yes,
provide further info
No
Yes
(Further Info:
)
16.
How often are the vehicles serviced?
17.
Is there any equipment or machinery
attached to vehicles?
(i.e.Reefer, Hoists/Loader of Cranes)
No
Yes
N/A
18.
Do Reefers have warning lights or
indicators visible from the
drivers seat.
No
Yes
N/A
19a.
Does the Applicant haul any Hazardous
Goods as defined by the Hazardous Goods
Act?
No
Yes
19b.
If yes please describe:
20.
Does the Applicant require Legal
Liability for damage to Non
-Owned (interchange) Vehicles?
If Yes,
please advise below.
No
Yes
21.
Number in care at any one time value for the
vehicle (ACV)
TRACTORS NON-OWNED
TRAILERS NON-OWNED
AVERAGE
MAXIMUM
AVERAGE
MAXIMUM
$
$
$
$
#
#
#
#
22.
What is the frequency, in percent, that
the Applicant would
have non-owned vehicle/s in their care, custody, and
control?
%
23.
Does the Applicant do any team or
slipseating?
No
Yes
24.
Prior Carrier
Prior Policy No.
Normal Expiry Date
Premium:
25.
Does the Applicant comply with Government
Vehicle Inspections on all Commercial
Vehicles
No
Yes
COMMENTS
GROSS REC.
AUTO COUNT
NEXT YEAR
THIS YEAR
LAST YEAR
PRIOR YEAR
26.
THIRD PARTY LIABILITY REQUIRED
$
27.
Description of Equipment
Year
Trade Name & Type
Serial Number
Legally Owned By
Today’s Value
Physical Damage Cov. & Ded. Requested
1.
2.
3.
4.
5.
6.
28.List of Drivers
Name
D.O.B
Drivers License Number
Experience with this Type of Vehicle
Date Employed
Any
Conv.
1.
2.
3.
4.
5.
6.
29.Loss
Experience - Please include all claims for
the past 4 years (Auto, Cargo, CGL) for the
company and/or
drivers with less than 3 years employment
with the company.
Date of Loss
Coverage
Description of Loss
Amount Paid and/or Reserved
Please attach current MVR's and
confirmed loss experience from
previous insurer.
(Minimum Requirement is 3 years)
ENCLOSED
CARGO
30.
Cargo limit Required? $
Deductible:
31.
Are
hazardous, volatile, flammable,
corrosive good carried? If yes,
refer to company.
No
Yes
32.
Are there any
products hauled which require
heating or refrigeration?
No
Yes
%
33.
Is
Contingent Cargo Legal Liability
Coverage for loads brokered to
others required?
No
Yes
%
34a.
Do
you obtain certificate of insurance
on brokered loader?
No
Yes
34b.
Do
you do any warehousing?
No
Yes
35.
What percentage of goods hauled are
owned?
%
Do you have any side agreements for
load values?
Commodity
%
Average Load Value
Max. Load Value
#
TimesReach Max. Value
COMMERCIAL GENERAL LIABILITY
THIS COVERAGE IS INTEDED FOR
TRUCKMEN. (COMMON/CONTRACT CARRIERS
ONLY)
36. Coverage Requried:
Yes
No COMBINED SINGLE
LIMIT:
37. Does the Applicant
conduct any other operation
other than
the transportation of goods? If yes, please
provide info.
Yes
No
38.Broker Information
Broker Name:
Broker Address:
Phone #:
Fax #:
39. Is this risk new to your
office?
Yes
No
Electronic Signature of Insured (use
e-mail address)
Date:
Please use this area to include any
additional information: e.g. Driver’s
List, Milage Reports, Equipment
List, Claims history’s and anything
you feel would be of assistance.
