1
General Information
2
Prior Carrier
3
Equipment
4
Driver

General Information

Dates Coverage Desired

All policy terms are for 1 year from the selected date.

Description of Operations

Indicate Cities Traveled Into or Through

Commodities Transported

List shipper requirements (if any)

If trip leased, provide the annual estimated cost of hire:

Non-Fleet Insurance
Label: Your Field Value

APPLICANT PRIOR CARRIER AND LOSS INFORMATION

LIABILITY INFORMATION - CURRENT YEAR AND PREVIOUS 2 YEARS MUST BE SHOWN

PHYSICAL DAMAGE INFORMATION - CURRENT YEAR AND PREVIOUS 2 YEARS MUST BE SHOWN

CARGO INFORMATION - CURRENT YEAR AND PREVIOUS 2 YEARS MUST BE SHOWN

COVERAGES

Limits - Combined single limit (BI/PD)

Hired and Non/Owned coverage only available if contractually required.

Estimated # of days vehicle hired in 12 months

Combined Deductible

Physical Damage

Cargo

Refrigeration Breakdown

Temperature controlled units must be inspected at least monthly and inspection records must be maintained and retained for at least one year.

Extras Endorsement

Towing Coverage

Are all vehicles equipped with theft alarms?

Are all vehicles equipped with fire extinguishers?

Are there any overages, shortages or damage claims pending?

Are any vehicles left loaded overnight?

Are vehicles left unlocked when unattended?

Does named insured transport own goods?

Non-Fleet Insurance
Label: Your Field Value

EQUIPMENT

Show number of units below

Is special equipment mounted or attached?

Do you enter construction site?

Is mobile equipment used in any other operation other than your own, specifically for loading and unloading?

Do You Pull

Double trailers?

Triple trailers?

SCHEDULE OF AUTOS TO BE INSURED

All units you own or that are leased to you must be scheduled and insured if filings are to be made

LIENHOLDER / ADDITIONAL INSURED INFORMATION

Non-Fleet Insurance
Label: Your Field Value

DRIVER INFORMATION

Must be completed for all drivers.

Do you use PSP?

Number of violations:

DRIVER EMPLOYMENT HISTORY

If you have not had insurance for the past two years in your name, provide three years employment history for each driver.
Do not indicate "self-employed" unless you have had insurance in your name.

Non-Fleet Insurance
Label: Your Field Value