Freight Broker Application
Please complete our consolidated application and select the applicable coverages.
Who is completing this application?
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Insurance Broker
Freight Broker
Freight Broker Name
Freight Broker DOT #
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Freight Broker MC #
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Type of Entity
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Corporation
LLC
Sole Proprietorship
Partnership
Freight Broker mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Freight Broker Contact
Title
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Freight Broker Website
Years in Business
Proposed Effective Date
-
Month
-
Day
Year
Date
Is the Applicant a Motor Carrier?
Yes
No
Motor Carrier DOT #
Motor Carrier MC #
Are the Applicant's Freight Broker and Motor Carrier authorities separate legal entities?
Yes
No
% Volume Provided to Third Party MCs
% Volume Provided to Own MC
Does the Applicant have a Broker Carrier Agreement (BCA) in place with their own Motor Carrier?
Yes
No
Is the Applicant named as an Additional Insured on their Motor Carrier's insurance policies?
Yes
No
Is the Applicant a Freight Forwarder?
Yes
No
Is the Applicant's Freight Forwarder Authority in a separate legal entity to its Freight Broker and/or Motor Carrier Authorities?
Yes
No
Exposure Information
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Rows
$ Current Annual
12-month Forecast
Gross Revenue
Number of Loads
Annual Truckload Revenue %
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Annual LTL Revenue %
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Less-Than-Truckload (LTL)
Annual Rail Revenue %
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Annual Parcel Revenue %
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Annual Air Revenue %
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Annual Sea Revenue %
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What type(s) of cargo do you arrange transportation for?
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Motorized and other vehicles
Mixed freight
Machinery
Miscellaneous manufactured products
Other fossil fuel products
Other prepared foodstuffs
Plastic and rubber
Gasoline, kerosene and ethanol
Textiles
Precision Instruments
Diesel and other fuel oils
Articles of metals
Metal in basic shapes
Other agricultural products
Furniture
Chemical products and preprations
Other transportation equipment
Meat and seafood
Crude petroleum
Basic chemicals
Non-mettalic mineral products
Wood products
Milled grain products
Pulp, paper and paperboard
Cereal grains
Paper or paperboard articles
Printed products
Feed and products of animal origin
Waste and scrap
Fertilizers
Coal
Gravel and crushed stone
Metallic ores
Other non metallalic materials
Logs and wood in the rough
Other
What other specific type of cargo is being arranged for transportation?
Will the insured be responsible for brokered loads involving High Value commodities?
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Yes
No
Which High Value commodities do you broker?
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Alcoholic Beverages
Motor Vehicles
Boats
Mobile Homes
Pharmaceutical Products
Tobacco, Cannabis, THC & Vaping Products
Live Animals
Cash, Currency, Precious Metals or Minerals, Diamonds, Precious or Semi-Precious Stones or Jewelry
Non-ferrous metals in sheet, bar, ingot, tube, oil or similar form; including but not limited to copper, aluminum, brass, nickel, zinc, titanium
Electronics (including mobile hones, pre-paid mobile telehones vouchers, SIM card, and like accessories)
Tires
Medical Equipment, Supplies, Blood, Organ, and Tissue Samples
Personal Effects
Antiques or historic artifacts
Clocks and watches and components for clocks or watches
Fur, leather or garments made from fur and leather
Works of Art
None
Total Gross Revenue of High Value Comm $
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Revenue %
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Please provide full details of what is being shipped.
Please provide details of your carrier vetting procedure when moving this type of product.
Are any shipments of these cargoes posted on public Load Boards?
Yes
No
PLEASE CONFIRM YOU OPERATE AS FOLLOWS AND WITHOUT EXCEPTION
You maintain a hard copy or electronic file on each motor carrier to whom you assign loads which includes a copy of the motor carrier authority, a certificate of insurance, and the signed broker carrier agreement?
Yes
No
You assign loads only to carriers rated Satisfactory or Unrated by FMCSA?
Yes
No
You prohibit a shipper or a carrier from issuing a bill of lading in your name?
Yes
No
You reject motor carriers who possess insurance with less than an A- financial rating from A.M. Best?
Yes
No
You require a signed Broker Carrier Agreement (BCA) from all motor carriers before they are approved to haul a load?
Yes
No
Is the Applicant responsible for any packaging, loading or unloading of any cargoes being transported by a Motor Carrier they have contracted with?
Yes
No
Does the Applicant operate a written carrier qualification procedure (e.g. T.I.A. Framework) for vetting carriers?
Yes
No
Are all employees responsible for booking shipments trained in, and required to follow these procedures?
Yes
No
Are all employees responsible for booking shipments mandated to only use pre-approved Motor Carriers?
Yes
No
Does the Applicant use a Carrier Management Vetting System like "HIGHWAY or RMIS"?
Yes
No
Does the Applicant verify each carrier’s DOT, MC number, and BOC-3 with FMCSA?
Yes
No
Does the Applicant mandate a minimum number of years in business a Motor Carrier has been operating for before they will consider contracting with them?
Yes
No
Does the Applicant contract exclusively with Motor Carriers who have For-Hire Common and/or Contract Carrier Authority?
Yes
No
Does the Applicant obtain a copy of the Motor Carrier’s Certificate(s) of Insurance Certificate from the Motor Carrier’s insurance agent directly and not from the Motor Carrier?
Yes
No
Please provide a copy of your broker carrier agreement.
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Does the BCA require the Motor Carrier to haul under their own authority and contain a clause to prevent Double Brokering?
Yes
No
Does the BCA require full indemnification from the Motor Carrier for any Loss?
Yes
No
Does the BCA define carriers as "Independent Contractors"?
Yes
No
Does the BCA contain a clause detailing the requirements for moving refrigerated and/or perishable cargoes?
Yes
No
Does the BCA require the Motor Carrier to maintain a "Satisfactory" U.S. DOT safety rating and contain a clause to the effect that "under no circumstances is the Motor Carrier allowed to provide services under this Contract if their Safety Rating falls to 'Unsatisfactory' or 'Conditional'?
Yes
No
It is a condition precedent to the liability of the Insurers hereon that the Insured ("Applicant") must have in place a signed Broker Carrier Agreement with all parties with whom the Insured contracts Motor Carrier services in a formTo ensure you have adequate protection, please upload the current coverages (ex. Declaration page, Acord form, Policy) you are requesting. This will help us assist you more effectively. This is Optional.
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FREIGHT BROKER COVERAGE REQUESTED
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Freight Broker Liability
Contingent Auto Liability
Contingent Cargo Liability
Professional Liability / Errors and Omissions
Cyber
General Liability
Excess Liability
Freight Broker Liability
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Rows
Limit Requested
Current Limit
1.
Contingent Auto Liability
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Rows
Limit Requested
Current Limit
1.
Contingent Cargo Liability
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Rows
Current Limit $
Limit Requested $
1.
Professional Liability / Errors & Omissions
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Rows
Limit Requested
Current Limit
1.
Cyber
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Rows
Limit Requested
Current Limit
1.
General Liability
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Rows
Limit Requested
Current Limit
Please provide square footage of your operations.
Please provide the number of employees.
1.
Excess Liability
Amount Requested
Please provide the type of Excess Liability
Are there Additional Insureds?
Yes
No
Please upload a list of shipper’s names addresses of the Additional Insureds
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Are Waivers of Subrogation required?
Yes
No
Please upload a list of shipper's name & addresses.
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Does the Applicant require every Motor Carrier to carry Broad Form / All Risk Cargo Insurance with limits at least equal to the value of each shipment?
Yes
No
Does the Applicant ensure that such Cargo Insurance does not include an exclusion for Unattended or Unlocked vehicles?
Yes
No
Does the Applicant arrange shipments of refrigerated and/or perishable cargoes?
Yes
No
Does the Applicant confirm that all Motor Carriers have refrigeration units on a regular service contract?
Yes
No
Does the Applicant require that all Motor Carriers have Refrigeration Breakdown insurance coverage?
Yes
No
Percentage of refrigerated loads moved annually
Does the Applicant arrange shipments of cargo hauled on flatbed trailers?
Yes
No
Does the Applicant require that all Motor Carriers tarp all loads, if required by shipper?
Yes
No
Percentage of Flatbed Loads moved annually
Have you purchased shipper's interest insurance?
Yes
No
How many transactions - past 12 months?
Loss History
For all coverages requested, have you had any covered or non-covered losses in the past 5 years?
Yes
No
Were all losses covered by primary insurance?
Yes
No
Please upload a document providing full details on all losses.
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Please provide a "No Known or Reported Losses" statement on the Applicant's letterhead and signed and dated by an Officer of the Applicant company.
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In the past 5 years, have you ever had insurance cancelled, declined or the policy renewal refused?
Yes
No
Please provide any additional information necessary to support this application.
I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the Insurance Company.
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