Motor Carrier Application

Motor Carrier Application

Please complete the following questionnaire to apply.
Motor Carrier Information
Company Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Garaging/Terminal Address
DOT #
MC #
Website
Years in Business
Coverages Requested

ALAPDMTCGLHNO
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Operations
Description of Operations
Brokerage Operations?

YesNo
Last Year's Brokerage Revenue (if any)
Separate Operating Authority?

YesNo
Projected Brokerage Revenue
If yes, Name of Brokerage Company
Business Type

For-Hire CorporationPrivate CarrierOther
Other
Equipment

	Owned (Company Drivers)	Leased (Owner/Operators)
Tractors
Trucks
P/P Vehicles
Service Vehicles
Trailers
Other

	Yes	No	If Yes, indicate Cost of Hire $
Any Sub Hauling

	Yes	No	If Yes, indicate Percentage %
Double or Triple Trailers
Flatbeds
Oversize/Overweight
Slip Seating
Team Drivers
Back Hauling
Dead-Heading

Radius
0-50 Miles
51-200
201-500
501+
Average Length of Haul
Maximum Length of Haul
Commodities
Please upload commodities hauled by commodity category, percentage of the total loads hauled, maximum value, average value.

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Please upload commodities hauled by commodity category, percentage of the total loads hauled, maximum value, average value.

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Refrigeration Breakdown?

YesNo
Any Hazardous Commodities?

YesNo
If yes, details
Projected Historical Exposures

Policy Period

	Truck Revenue	Brokerage Revenue	Miles	Units
Next Year
Current Year
Previous Year
Previous Year 1
Previous Year 2
Previous Year 3

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MOST RECENT FINANCIALS

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IFTA REPORTS

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IFTA REPORTS

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Auto Liability
Auto Liability Loss Experience Summary (ground up and uncapped)

Upload hard copy, Auto Liability carrier issued loss runs - Currently valued for the last 5 years.

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Upload hard copy, Auto Liability carrier issued loss runs - Currently valued for the last 5 years.

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DETAILS OF CLAIMS XS $25,000. If any claims have penetrated in Umbrella/Excess layer, provide hard copy Umbrella/Excess loss runs

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DETAILS OF CLAIMS XS $25,000. If any claims have penetrated in Umbrella/Excess layer, provide hard copy Umbrella/Excess loss runs

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Auto Physical Damage
Auto Physical Damage Loss Experience Summary (ground up and uncapped).

TIV for APD (stated values)
CURRENT VEHICLE SCHEDULE WITH TIV (TIV only required if APD needed – current stated values)

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CURRENT VEHICLE SCHEDULE WITH TIV (TIV only required if APD needed – current stated values)

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Upload hard copy, Auto Physical Damage carrier issued loss runs - Currently valued for the last 5 years.

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Upload hard copy, Auto Physical Damage carrier issued loss runs - Currently valued for the last 5 years.

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Motor Truck Cargo
Upload hard copy, Motor Truck Cargo carrier issued loss runs - Currently valued for the last 5 years

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Upload hard copy, Motor Truck Cargo carrier issued loss runs - Currently valued for the last 5 years

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General Liability
Payroll - Drivers
Payroll – Other than Drivers
# Of Terminals
Any Warehousing
Confirm no GL losses in the last 5 years, or advise details
Upload hard copy, General Liability carrier issued loss runs - Currently valued for the last 5 years.

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Upload hard copy, General Liability carrier issued loss runs - Currently valued for the last 5 years.

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HNO
Is Hired/Non Owned Needed?

YesNo
If Yes, provide annual cost of hire
Num. of Employees
Driver & Safety Information
Is it company policy that all on-board computer systems are turned off while vehicle is in gear?

YesNo
If yes, is this conveyed to the drivers in writing?

YesNo
Driver Turnover Percentage
Percentage of drivers with less than 1 year with company
Do you allow passengers?

YesNo
If yes, do you have a written passenger program in place, including signing waivers?

YesNo
How often do drivers get home? (Indicate number of days or number of weeks)
Days / Weeks
How long are drivers on the road? (Indicate maximum number of hours per day/per week)
Hours per day / Hours of week
Max Age of Drivers
Min Age of Drivers
Are the owner/operators and/or fleet operators subject to the same rules and regulations as company drivers?

YesNo
Is there a formal safety program?

YesNo
How often are safety meetings held?
Safety Director Name and Phone #
Is there a Driver Safety Incentive Program?

YesNo
Explain
Is there a formal vehicle maintenance program?

YesNo
How often is routine maintenance performed?
Are MVRs checked prior to hiring?

YesNo
How often thereafter?
Accident Analysis / Correction Action?

YesNo
What percentage of drivers are hired from driving schools?
Is there a Driver Orientation and/or training program?

YesNo
How are drivers compensated? (% of load, Mileage, Hourly)
DRIVER LIST WITH DOB AND DOH + CURRENT MVRs

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DRIVER LIST WITH DOB AND DOH + CURRENT MVRs

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COPY OF SAFETY MANUAL

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COPY OF SAFETY MANUAL

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Technology

	Owned (company drivers) Yes/No	% of Units (if yes)	Leased (Owner/Operators) Yes/No	% of Units (if yes)
Roll Stability Control
Forward Facing Cameras
Driver Facing Cameras
Side and Rear Cameras
Video Event Recorder
LED Headlights
Lane Departure Warning Systems
Collision Mitigation Braking
Governors/Speed Limiters
Blind Spot Warning
Adaptive Cruise Control
Real-Time Vehicle Diagnostics
Anti-Lock Braking
E-logs
Satellite GPS Tracking

Expiring Coverages

	Auto Liability	Physical Damage	General Liability	Motor Truck Cargo
Insurance Company
Limits
Ded/SIR
Rate & Premium

Additional Information
Upload any additional Information

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Upload any additional Information

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Agency Information
Agent Name

First NameLast Name
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Declaration
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. I/We hereby declare that the statements and particulars given on this form are true to the best of my/our knowledge and belief and that I/we have not suppressed, withheld, or modified any material fact(s). I/We agree that should a policy be issued, this form shall be the basis of the contract, and that any change in the pattern of my/our trade or trade practices shall be advised to the Underwriters as soon as possible, who may, at their discretion, vary the terms and conditions of the contract. (Please enter your full name and sign that you have read and agree to the above disclaimers).
Signature*

Clear
Name
Date*

MonthDayYear
Date
Should be Empty:

Motor Carrier Application

Motor Carrier Information

Operations

Equipment

Radius

Commodities

Projected Historical Exposures

Auto Liability

Auto Physical Damage

Motor Truck Cargo

General Liability

HNO

Driver & Safety Information

Technology

Expiring Coverages

Additional Information

Agency Information

Declaration