• Application for Commercial Policy

    Please complete and sign.

  • Submission

  • Submission Type*
  • Proposed Effective Date – From*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Proposed Effective Date – To*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Need-By Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Office Use Only

  • General Information

  • Entity Type*
  • Format: (000) 000-0000.
  • Do you operate more than one terminal?*
  • Terminal Locations
    Rows
  • Format: (000) 000-0000.

  • Owner / Principal

  • Description of Operations

  • Type of Operation*
  • Do you engage in operations other than trucking?*
  • Has there been any change in the nature of operations, ownership, management or the name of the operation during the last five years?*
  • Commodities Hauled
    Rows
  • Range of Transport*
  • Metropolitan Areas Traveled Through or Into
  • 8. Percent of Loads — complete the row that applies to your policy state.
  • Are filings required?*
  • Do you arrange loads for others in your name or a different name, or act as a freight broker or freight forwarder?*
  • In circumstances where you are unable to accept a load (e.g., high capacity, unit down), do you hand off or refer loads to others?*
  • 11a. Is your name on the bill of lading or shipping documents?*
  • 11b. Do you obtain payment or financial gain from loads handed off or referred to others?*
  • 11c. Is there a written agreement?*
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  • Is all equipment operated under the applicant's authority scheduled on this application?*

  • Description of Operations (continued)

  • 13. Is all owned equipment scheduled on this application?*
  • 14. Do you lease your equipment to others?*
  • What do you lease to others?
  • Who must provide primary liability coverage?
  • 15. Do you pull doubles or triples?*
  • 16. Do you engage in any residential deliveries?*
  • 17. Is any portion of your operation seasonal?*
  • 18. Do you use any team, hot seat, slip seating or relay driver operations?*
  • 19. Do you allow passengers other than company employees?*
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  • 20. Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged?*
  • 21. Do you haul oversize or overweight loads?*
  • 22. Do you hire escort vehicles?*
  • Do you require escort vehicles to provide a certificate of insurance?*
  • 23. Do you haul to or from well drilling sites or mines?*
  • 24. Are any of your vehicles powered by a source other than diesel or gasoline?*

  • Owner Operator / Leased / Hired

  • Do other motor carriers or owner-operators haul for you?*
  • Name on the Bill of Lading
  • On what basis are they leased?
  • Are vehicles leased with driver? – Permanent basis
  • Are vehicles leased with driver? – Temporary / Trip basis
  • Are all leased vehicles included in this application for insurance? – Permanent basis
  • Are all leased vehicles included in this application for insurance? – Temporary / Trip basis
  • If any leased vehicles are not included, the T-565 Leased/Hired Autos Supplement must be completed, and questions a–d below must be answered.
  • a. Is there a written lease agreement stating the lessor will provide primary auto liability coverage while leased to you, and hold you harmless? – Permanent basis
  • a. Is there a written lease agreement stating the lessor will provide primary auto liability coverage while leased to you, and hold you harmless? – Temporary / Trip basis
  • b. Do you secure evidence the lessor has primary auto liability coverage? – Permanent basis
  • b. Do you secure evidence the lessor has primary auto liability coverage? – Temporary / Trip basis

  • Driver Information

  • List every driver below. If you have more than 10 drivers, do not use the table. Download the Excel template, fill in the Drivers tab, and upload it below.
  • Driver List
    Rows
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  • Drivers Hired or Leased Last Year
    Rows

  • Driver Hiring, Training and Safety

  • Indicate which of the following are part of your driver screening / hiring process
  • Indicate which of the following are part of your driver performance management process
  • Indicate which of the following are part of your written equipment management program
  • Do you have a Safety Director?*
  • Safety Director – Full Time or Part Time

  • Truck Technology

  • Are your trucks equipped with any of the following technologies? If none, leave blank.
    Rows
  • Do you use telematics data to manage drivers?*
  • Are your trucks equipped with technology that enables platooning, semi-autonomous, autonomous, or other similar operations?*

  • Units, Revenue and Mileage – Actual and Estimated

  • Units, Revenue and Mileage
    Rows
  • Does IFTA mileage include all Owner/Operator mileage?*

  • Insurance History and Loss Experience

  • Has an insurance company cancelled or non-renewed your policy in the last 3 years?
  • Prior Insurance Carriers
    Rows
  • Coverage Type: P = Physical Damage · C = Cargo · L = Primary Liability · N = Non-Trucking Liability · GL = General Liability · IM = Inland Marine. Provide currently valued (dated within the last 3 months), carrier-produced detailed loss and experience runs for auto liability, physical damage and cargo, as required.

  • Schedule of Equipment Operated

  • List every truck and trailer below. Choose how many units you have and a section opens for each one. If you have more than 10 units, choose "More than 10" instead. Download the Excel template, fill in the Vehicles tab, and upload it below.

  • Unit 1

  • Unit 2

  • Unit 3

  • Unit 4

  • Unit 5

  • Unit 6

  • Unit 7

  • Unit 8

  • Unit 9

  • Unit 10

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  • To ensure Electronics (as defined by the policy), along with tarps, chains or binders, are covered, include their value in each auto's stated value. Finance Value Coverage — The Stated Limit of each auto must be equal to or greater than the outstanding financial obligation for that auto in order for the Finance Value Coverage to apply.
  • Equipment Summary – number of units by type
    Rows

  • Coverages

  • Coverages requested
  • Reporting Basis
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  • Physical Damage coverages requested
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  • Do you want Cargo coverage?*
  • Optional Cargo Coverages
  • Rental Reimbursement*
  • Rental Reimbursement – Days of coverage

  • Supporting Documents

  • Our underwriters want to provide you with the quickest and most competitive quote possible. The more we know about your account, the easier it is to market it to our carriers and deliver the best available quote. Please attach the items below.
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  • Uninsured / Underinsured Motorists and No-Fault options: coverage and limit choices in this section are for quoting purposes only. A separate Insurance Company Supplemental Uninsured Motorists/Underinsured Motorists and Personal Injury Protection Application(s) must be completed and signed by the applicant when binding coverage.

  • Important Notices and Signature

  • IMPORTANT NOTICES — This application, including any material submitted in conjunction with this application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by the Insurance Company. It is not a representation that coverage does or does not exist for any claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.
  • Iowa, Illinois, New Mexico, Oregon, Washington and Wisconsin: The signing of this application does not bind the company to offer, nor the applicant to purchase, the insurance. It is agreed that this application, including any material submitted in conjunction with this application or any renewal, shall be the basis of the insurance and shall be considered physically attached to and part of the policy issued. The company will have relied upon this application, including any material submitted therewith, in issuing the policy.
  • FRAUD STATEMENTS — ARKANSAS, MARYLAND, NEW MEXICO and OREGON: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MAINE, TENNESSEE and WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits. NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim 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 and subjects the person to criminal and civil penalties.
  • I authorize the Insurance Company to obtain a copy of any Motor Vehicle Report for rating/underwriting the insurance for which I have applied. I also understand that a routine inquiry may be made providing information concerning my character, general reputation, personal characteristics and mode of living. Upon written request, information as to the nature and scope of the report will be provided to me.
  • Disclosure: In connection with this application for commercial automobile insurance, we may review a credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of the insurance score. The credit report/credit-based insurance score will not be used for any purpose other than the underwriting of the commercial automobile insurance policy for which you have applied. I authorize the Insurance Company to obtain a credit report, including but not limited to a credit-based insurance score based on personal information provided. This authorization is valid for future reports obtained for renewal policies with the Insurance Company.
  • By signing below, I declare that the statements contained herein are true and accurate, and that all commercially owned or operated vehicles have been disclosed to you and are listed on this Application. I further agree that I will immediately notify you of any changes to the drivers or vehicles put into service in the future, and that I will immediately report all accidents, losses or claims, regardless of fault or the severity of the damage or injury. I hereby certify that the foregoing statements and answers are a just, full and true exposition of all the facts and circumstances with regard to the risk to be insured, insofar as same are known to me, and the same are hereby made as the basis and condition of the insurance. By signing below, I affirm full knowledge of and adherence to current D.O.T. Safety Regulations and hereby apply for insurance with respect to the coverages stated herein.
  • State Notices — Montana: A single loss is among the insurance company's criteria for nonrenewal. South Carolina: The insurer can cancel this policy for which you are applying without cause during the first 90 days. That is the insurer's choice. After the first 90 days, the insurer can only cancel this policy for reasons stated in the policy.
  • Acknowledgment*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: