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

  • PLEASE ANSWER ALL QUESTIONS

  • DESCRIPTION OF OPERATIONS

  • Attach appropriate supplemental application as needed.

  • 16. Do you have a signed trailer interchange agreement?

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

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

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

  • DRIVER INFORMATION

  • Perform criminal background checks?

    Have a “Good Driver” incentive program

    Order MVRs prior to allowing employees to drive?

  • 28. Average driver turnover per year:

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

  • If no, provide copy of contract.

  • 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.

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  • Hire Date

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

  • VEHICLE INFORMATION

  • 38. Number of vehicles leased:

  • PRIOR CARRIER AND LOSS EXPERIENCE SUMMARY

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

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  • FILING INFORMATION

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

  • 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

  • Submit to company—financials may be required

  • Hired auto coverage is subject to audit.

  • Non-owned auto coverage is subject to audit.

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

    77. Optional no-fault state: PIP rejected?

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

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  • VEHICLE SCHEDULE

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

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

  • Clear
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  • (Applicable to Florida Agents Only)

  • IMPORTANT NOTICE

  • 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.

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  • Should be Empty: