Commercial Auto Application

Name of Company

Name of company contact

First

Last

Phone

Email

Address

City

State/Province

Zip/Postal

Country

DOT# (if applicable)

MC# (if applicable)

Other State Filings (Please provide ID #s if applicable)

States Entered

Major Cities Driving Into or Through

Prior Carrier Info for the past 3 years

Any previous claims?

No

Yes

Please Upload 5 Years Loss Run History Report

Maximum file size: 516MB

Please provide estimated date and amount of each claim

Driver and Vehicle Information

Provide full name, dates of birth, and drivers license numbers of each driver (or upload driver list)

Upload Driver List (Optional)

Maximum file size: 516MB

List the VIN numbers, year, make and model of each vehicle (or upload vehicle list)

Upload Vehicle List (Optional)

Maximum file size: 516MB

Provide all addresses where units will be parked when not operating

Coverage and Limits

Liability limit requested

$300,000

$500,000

$1 Million

Other

If Other, please provide details

Which vehicles do you want comprehensive and collision coverage on? (full coverage)

Dedectible

$1000

$2500

$5000

$10,000

Operational Details

Description of operations

How long has this operation been in business?

Is this for trucking or transportation operations?

No

Yes

How many years of experience does your management have in the truck/transportation business? (if applicable)

Have you had any insurance canceled, declined or non-renewed in the last three years?

No

Yes

If “yes” please explain

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

No

Yes

If yes please explain

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

No

Yes

If yes please explain

Is there a formal safety program?

No

Yes

If yes please explain

List commodities transported:

Any exposure to flammables, explosives, chemicals or hazardous materials (including medical or contaminated waste)?

No

Yes

If ‘YES’ Please provide details

Radius of operations:

Intrastate only

Interstate

0-100 miles (%)

101-300 miles (%)

301-500 miles (%)

Over 500 miles (%)

List all states in which vehicles operate:

For all states, list largest cities entered:

For all states, list farthest city entered from garaging location:

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

No

Yes

Do you haul for others?

No

Yes

If yes, indicate percentage and for whom:

Do you back haul?

No

Yes

If yes, advise for whom and commodities transported:

Do you have a signed trailer interchange agreement?

No

Yes

Are any units customized or altered, or do they have special equipment?

No

Yes

Do you have vehicles with mobile equipment permanently attached?

No

Yes

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

If other, please explain:

Are any vehicles used by family members?

No

Yes

If yes, explain:

Are any vehicles used for personal use

No

Yes

If yes, explain:

Do you allow passengers to ride in your vehicles?

No

Yes

If yes, explain:

Are all drivers covered by Workers’ Compensation insurance?

No

Yes

Are you familiar with the U.S. Department of Transportation driver requirements?

No

Yes

Do you maintain driver activity files?

No

Yes

Do you review current MVRs on all drivers prior to hiring?

No

Yes

Is there a formal driver hiring procedure?

No

Yes

Are all drivers employees?

No

Yes

If no, please explain:

How are your drivers paid?

Per load

Per hour

Other

If ‘other’, please provide details:

Is there a formal safety program?

No

Yes

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

No

Yes

Maximum number of hours driver will operate a vehicle in a 24-hour period:

Do you contemplate using double or triple trailers?

No

Yes

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

Do all trailers have DOT-required reflective tape?

No

Yes

Provide details on your vehicle maintenance program:

FILING INFORMATION

Do you hold an FHWA permit?

No

Yes

N/A

If yes, provide your docket number (MC#) and base state:

State filings required?

No

Yes

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

Show exact name and address in which permits are to be issued:

Are there any special requirements needed for City permits, Certificates of Insurance, oversize and/or overweight permits?

No

Yes

If yes, provide details:

HIRED AUTO INFORMATION

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

No

Yes

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

What is the average term of the lease?

Is there a written agreement?

No

Yes

Does your lease agreement contain a Hold Harmless clause?

No

Yes

N/A

Do you obtain a copy of the insurance form that lists “named lessee as insured” from the truckers you hire?

No

Yes

N/A

Do you obtain certificates of insurance from the truckers you hire?

No

Yes

N/A

Certificates of insurance with limits of at least $750,000 are required from your sub-haulers. If you do not have these on file when we audit, we will charge you for primary hired auto insurance. Do you understand?

No

Yes

If owner/operators are leased for six (6) months or longer, will they be scheduled on your policy?

No

Yes

N/A

Do you lease, hire, rent, or borrow any vehicles from others without drivers?

No

Yes

Will they be scheduled on the policy?

No

Yes

What is your cost to lease, hire, rent or borrow vehicles? (WITH Drivers)

What is your cost to lease, hire, rent or borrow vehicles? (WITHOUT Drivers)

Estimated cost of hired autos: (This Year)

Estimated cost of hired autos: (Last Year)

What type of vehicles do you lease, hire, rent or borrow?

At any time will your employees, subcontractors, or owner/operators lease vehicles in your name?

No

Yes

If yes, explain:

Do you arrange or dispatch loads for others, not including your own hired truckers?

No

Yes

If ‘yes’ please explain:

Are you named on the Bills of Lading?

No

Yes

Annual number of Truckers

Annual number of Loads

Do you have brokerage authority?

No

Yes

If yes, is the brokerage authority held under the same name and motor carrier number as your trucking operation?

No

Yes

What is your brokerage motor carrier number?

Whose name appears on the bill of lading as the carrier?

What is your brokerage revenue for the most recent twelve (12) months?

Estimated next twelve (12) months?

Are driver teams used?

No

Yes

Will more than one driver use a specific truck?

No

Yes

NON-OWNED AUTO INFORMATION

Will ANY NON-OWNED AUTO be used in your business?

No

Yes

What types of non-owned autos will be used in your business?

Total number of non-owned autos used:

How will they be used?

How often are non-owned autos used in your business?

Daily

Weekly

Monthly

Other

Estimate the number of hours per month:

Estimated annual mileage for use of all non-owned autos:

Do any employees use their autos in your business?

No

Yes

If yes, what limit of liability insurance are they required to maintain?

Do you require evidence of insurance?

No

Yes

Do employees lease autos on your behalf?

No

Yes

If yes, under whose name are the autos leased?

Employee Name

Your Name

Will you use non-owned autos other than those owned by employees?

No

Yes

If yes, describe the relationship

Total number of employees:

Total number of officers and partners:

If a social service operation, indicate the total number of volunteers furnishing autos in your operation:

Maximum number of volunteers at any one time:

How will they use their vehicles?

Are volunteers required to have their own insurance?

No

Yes

Minimum limits required:

Do you obtain motor vehicle records for all drivers?

No

Yes

Do you understand that we may audit your records for Hired and Non-Owned auto exposure, which might result in an additional premium?

No

Yes

Signature

Clear