COMMERCIAL AUTOMOBILE - NEW BUSINESS APPLICATION

Name of Applicant

Street Address

P.O. Mailing Address

PROPOSED EFFECTIVE DATE

Date

12:01 A.M., Standard Time, at the mailing address of the Applicant.

( Phone )

FEIN/Social Security/Soundex No.

Individual

1.Applicant is: Partnership Corporation Joint Venture LLC Other

2.Description of operations

Attach appropriate supplemental application as needed.

3.How long has this operation been in business?

4.How many years of experience does your management have in the truck/transportation business?

Provide an explanation of their experience

5.Have you had any insurance canceled, declined or non-renewed in the last three years (Not applicable in Missouri?

Yes No

If yes, explain

6.Has there been any change in the nature of operations, ownership, management or the name ofthe operation during the last five years?

Yes No

If yes, provide details

7. Is the applicant a subsidiary of another entity, does the applicant have any subsidiaries or hasthe applicant operated under a different name?

Yes No

If yes, provide details

8. Is there a formal safety program?

Yes No

If yes, provide details or a copy

9. List commodities transported

10. Any exposure to flammables, explosives, chemicals or hazardous materials (including medicalor contaminated waste?

Yes No

If yes, provide specific details

Intrastate only

11. Radius of operations: Interstate

0-100 miles

%, 101-300 miles

%, 301-500 miles

%, Over 500 miles

12. List all states in which vehicles operate

a. For all states, list largest cities entered

b. For all states, list farthest city entered from garaging location

13. Is your operation subject to time constraints when delivering the commodity?

Yes Yes

13. Is your operation subject to time constraints when delivering the commodity?

No No

If yes, indicate percentage and for whom

15. Do you back haul?

Yes No

If yes, advise for whom and commodities transported

16. Do you have a signed trailer interchange agreement?

If yes, provide a copy of the signed agreement, cover letter and provider list.

17. Do you operate under a UIIA (Uniform Intermodal Interchange Association) contract?

Yes Yes Yes

17. Do you operate under a UIIA (Uniform Intermodal Interchange Association) contract?

No No No

If yes, provide a copy of the signed contract, cover letter and provider list.

18. Do any units have special equipment, customizations or alterations?

a. If yes, describe

b. If a boom, how far does the collapsed length of the boom extend beyond the front or rear bumper?

19. Are any vehicles used by family members?

Yes No

If yes, list and provide MVRs

20. Is there personal use of vehicles?

Yes No

If yes, explain

21. Do you allow passengers?

Yes No

If yes, explain

22. Are any vehicles or equipment loaned, rented, or leased to others?

Yes No

If yes, explain

23. Are all drivers covered by Workers’ Compensation insurance?

Yes No

Perform criminal background checks?

Have a “Good Driver” incentive program

Order MVRs prior to allowing employees to drive?

27. Criteria for hiring drivers: minimum age

years of experience

Describe MVR standards

28. Average driver turnover per year:

Number of drivers hired in the past twelve (12) months:

29. Is there an accident review procedure?

Yes No

Yes

If yes, please describe

30. Are all drivers employees?

Yes No

If no, provide copy of contract.

31. How are your drivers paid?

Per load Per hour Other

32. Do you agree to screen and report all potential operators immediately upon hiring?

Yes No

33. Maximum number of hours driver will operate a vehicle in a twenty-four (24) hour period

35. Are drivers assigned to specific units?

Yes Yes

35. Are drivers assigned to specific units?

No No

36. List below all drivers, owners/officers, partners currently employed as of the proposed effective date. If a Non- Owned auto is to be considered, you must list information for all employees currently employed by you.

Years Driving

	Driver’s Name	D/C	Date of Birth	Driver’s License No.	State	No. of Class of License Similar Vehicle	-	(M/D/Y)	List Past Three Years of Accidents & Traffic Violations

*Designation Code: O—Owner/Officer, P—Partner, E—Employee

37 Number of vehicles owned 1

Light Medium Heavy Extra Heavy

Tractors Trailers Private Passenger Types

38. Number of vehicles leased:

38 Number of vehicles leased 1

Light Medium Heavy Extra Heavy

Tractors

Trailers

39. Do you use double or triple trailers?

Yes No

Yes

If yes, what percentage of trips involves the use of multiple trailers?

40. Do all trailers have DOT-required reflective tape?

Yes No

41. Provide details on your vehicle maintenance program

42. Are any vehicles owned, operated or leased that are not included in the vehicle schedule?

Yes No

If yes, provide details

Include a minimum of four years currently valued company loss runs for all accounts.

The following Prior Carrier and Loss Experience Section must be completed:

	Policy Period	Prior Carrier	Policy No.	Past Deductible Amount	Liability Premium	Physical Damage Premium	No. Of Losses	Liability Losses Paid/ Open	Physical Damage Losses Paid/ Open

OPERATION HISTORY

	Year	Gross Receipts	Mileage	Number of Power Units

OPERATION HISTORY

	-	-	-
Current Year
Projected for Coming Year

43. Do you hold an ICC/FHWA permit or UCRA/DOT registration?

Yes No

If yes, provide: US DOT No.

, MC No.

, Base State

44. State filings required?

Yes No

If yes, list states and provide necessary state motor carrier number, if applicable

If yes, list states and provide necessary state motor carrier number, if applicable:

45. Provide exact name and address as shown on application for filings, permits, certificates, etc.

46. Are there any special requirements needed for City permits, Certificates of Insurance, oversize

and/or overweight permits?

Yes No

If yes, provide details

48. Do you lease, hire, rent or borrow any vehicles from others?

Yes No

What is the average term of the lease?

Does it include a Hold Harmless agreement and/or Additional Insured clause?

Provide a copy of the agreement.

49. Do you hire independent contractors?

If yes, do you require certificates of insurance?

Provide a copy of the contract.

50. If owner/operators are leased, will they be scheduled on your policy?

If yes, provide a copy of the agreement you use.

LIMIT AND COVERAGE INFORMATION

72. Liability: Combined Single Limits

Split Limit: B.I. Per Person

B.I. Per Accident

Property Damage

$1,000

Liability Deductible: Over $1,000

Over $1,000

Submit to company—financials may be required

73. Hired Auto: Cost of Hire

Hired auto coverage is subject to audit.

74. Non-owned Auto: Number of: Partners: Employees: Volunteers

Non-owned auto coverage is subject to audit.

75. Uninsured Motorist

Rejected Limits Accepted

Limits Accepted

76. Underinsured Motorist

Rejected Limits Accepted

Limits Accepted

(Complete appropriate UM/UIM Selection/Rejection Form for Questions 75. and 76.)

77. Optional no-fault state: PIP rejected?

78. Mandatory no-fault state: PIP basic limits accepted?

Yes Yes

78. Mandatory no-fault state: PIP basic limits accepted?

No No

(Complete appropriate Personal Injury Protection Selection/Rejection Form for Questions 77. and 78.)

Rejected

79. Medical Payments: Limits accepted:

Limits accepted

80. Trailer Interchange: Limit

Number of Trailers

Comp

Deductibles:

Comp

SCOL

Comp

Coll

SCOL

Coll

81. Do you understand that we may audit your records, which might result in an additional

Yes Yes

82. Are any Lessors or other entities to be added as additional insureds?

No No

If yes, list:

	NAME	VEHICLE	ADDRESS	RELATIONSHIP/INTEREST

(Attach copies of the vehicle registration for all vehicles and explain if registration name is different from applicant’s name

Vehicle No.

Year

V.I.N.

Make/model/type of vehicle

ACV ST AMT:

ST AMT

Value of perm. attached equip.

Radius

Farthest city

City, state, zip where garaged

License state

License plate No.

GVW/GCW

Class.

Deductibles

COMP

Deductibles

SCOL

Deductibles

COLL

Deductibles

Commercial Retail Service

COMP

SCOL

COLL

Leased Vehicle?

Yes No

Loss payee/additional insured/lessor

If limousine, name of coach builder

Length

Vehicle No.

Year

V.I.N.

Make/model/type of vehicle

ACV ST AMT:

ST AMT

Value of perm. attached equip.

Radius

Farthest city

City, state, zip where garaged

License state

License plate No.

GVW/GCW

Class.

Deductibles

COMP

Deductibles

SCOL

Deductibles

COLL

Deductibles

Commercial Retail Service

COMP

SCOL

COLL

Leased Vehicle?

Yes No

Loss payee/additional insured/lessor

If limousine, name of coach builder

Length

Vehicle No.

Year

V.I.N.

Make/model/type of vehicle

ACV ST AMT:

ST AMT

Value of perm. attached equip.

Radius

Farthest city

City, state, zip where garaged

License state

License plate No.

GVW/GCW

Class.

Deductibles

COMP

Deductibles

SCOL

Deductibles

COLL

Deductibles

Commercial Retail Service

COMP

SCOL

COLL

Leased Vehicle?

Yes No

Loss payee/additional insured/lessor

If limousine, name of coach builder

Length

Vehicle No.

Year

V.I.N.

Make/model/type of vehicle

ACV ST AMT:

ST AMT

Value of perm. attached equip.

Radius

Farthest city

City, state, zip where garaged

License state

License plate No.

GVW/GCW

Class.

Deductibles

COMP

Deductibles

SCOL

Deductibles

COLL

Deductibles

Commercial Retail Service

COMP

SCOL

COLL

Leased Vehicle?

Yes No

Loss payee/additional insured/lessor

If limousine, name of coach builder

Length

Vehicle No.

Year

V.I.N.

Make/model/type of vehicle

ACV ST AMT:

ST AMT

Value of perm. attached equip.

Radius

Farthest city

City, state, zip where garaged

License state

License plate No.

GVW/GCW

Class.

Deductibles

COMP

Deductibles

SCOL

Deductibles

COLL

Deductibles

Commercial Retail Service

COMP

SCOL

COLL

Leased Vehicle?

Yes No

Loss payee/additional insured/lessor

If limousine, name of coach builder

Length

APPLICANT’S NAME AND TITLE

APPLICANT’S SIGNATURE

Clear

DATE

Date

(Must be signed by an active owner, partner or executive officer

PRODUCER’S SIGNATURE

Clear

DATE

Date

AGENT NAME

AGENT LICENSE NUMBER

(Applicable to Florida Agents Only)

As part of the underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

PLEASE ANSWER ALL QUESTIONS

DESCRIPTION OF OPERATIONS

DRIVER INFORMATION

Hire Date

VEHICLE INFORMATION

PRIOR CARRIER AND LOSS EXPERIENCE SUMMARY

FILING INFORMATION

VEHICLE SCHEDULE

IMPORTANT NOTICE