Producer:
Agent:
Years in Business:
Yrs Oper. In Name:
Named Insured:
FEIN:
Policy Period:
Address:
Contact Name:
From:
Phone:
Email Address:
Garaging Location(s) if different:
Description of Operations:
MC Number
DOT Number
Brokerage Operations:
YES
Separate Operating Authority: Yes
Name of Brokerage
Other Named Insureds
NO
No
Last Year’s Brokerage Revenue
Percentage of Loads from Brokerage:
Yes
No
What is required before brokering loads:
President:
VP/General Manager:
Safety Director Name and Phone #:
Business Type:
To:
Fax:
Inspection Contact:
Individual
Partnership
Common Carrier
Contract Carrier
Corporation
Private Carrier
SHOW PERCENT OF OPERATIONS IN AND THROUGH
%
Atlanta
%
Detroit
%
Miami
%
Pittsburgh
%
Baltimore/Washington
%
Hartford
%
Milwaukee
%
Portland
%
Boston
%
Houston
%
Mpls/St. Paul
%
Richmond
%
Buffalo
%
Indianapolis
%
Nashville
%
St. Louis
%
Charlotte
%
Jacksonville
%
New Orleans
%
Salt Lake City
%
Chicago
%
Kansas City
%
New York City
%
San Diego
%
Cincinnati
%
Little Rock
%
Oklahoma City
%
St. Francisco
%
Cleveland
%
Los Angeles
%
Omaha
%
Seattle
%
Dallas/FTW
%
Louisville
%
Phoenix
%
Tulsa
%
Denver
%
Memphis
%
Philadelphia
%
Projected Equipment:
P/P Vehicles
Owned (Employed Drivers)
Leased (Owner/Operator)
Service Vehicles
Trucks
Tractors
Trailers
Others
Sunforest Transportation Insurance Group, Inc.
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1
Do you intend on adding units this year?
YES
NO If yes, how many power units?
VEHICLE MAINTENANCE PROGRAM
Have written/scheduled maintenance program?
Yes
No
Maintenance records kept on individual vehicles?
Yes
No
Does applicant service owned vehicles?
Yes
No
Does applicant monitor owner-operator vehicles for maintenance?
Yes
No
How often?
Does applicant service/repair other trucking firms' vehicles?
Yes
No
If yes, describe:
If yes, number of full-time mechanics:
Speed Governors
Yes
No
Satellite Tracking
Yes
No
Alarm on Vehicles
Yes
No
What is maximum speed?
Tractors
Trailers
Both
Do you currently use other Advanced Safety Technology?
Type of Equipment
Collision avoidance systems:
Usage, Capabilities, % of Fleet, etc.
Lane departure warning devices:
Advanced vehicle stability equipment:
Advanced brake monitoring equipment:
GPS equipment tracking:
Geo fencing:
Other (describe):
Do you currently use Electronic On-Board Recording (EOBR) equipment to monitor and
control Hours of Service?
1. What % of your fleet is equipped with EOBRs that are active whenever the CMV is in use?
Yes
No
2. What brand(s) of equipment do you use?
3. Describe the capabilities of the equipment you use (real-time hours of service (HOS) calculation, direct reporting of HOS availability, direct
reporting of HOS violations, etc.).
4. How often do you download/audit the EOBR results? Who reviews the EOBR records? How long are records kept?
5. Please provide copies of your last EOBR printouts to your Agent?
Does applicant have a tow truck(s)?
Yes
No
Tow vehicles of others?
Yes
No
Use temperature controlled equipment?
Yes
No
Mobile equipment; i.e., snowplows, forklifts, cranes,
cherry pickers, yard goats, etc.?
Yes
No
Does applicant haul containers? (Intermodal operations)
Yes
No
Has applicant signed the Intermodal Facilities Access Agreement?
Yes
No
Does applicant have interline agreement with another trucker?
Yes
No
If yes, how many?
If yes, please provide details:
Double or Triple Trailers?
Yes
No If Yes, indicate percentage
%
Flatbeds?
Yes
No (If yes, indicate percentage
%
Oversize/Overweight?
Yes
No (If yes, indicate percentage
%
Escort Vehicles?
Yes
No (If yes, indicate percentage
%
Team Drivers?
Yes
No (If yes, indicate percentage
%
Back Hauling
Yes
No (If yes, indicate percentage
%
Dead-Heading
Yes
No (If yes, indicate percentage
%
Passengers
Yes
No (If yes, indicate percentage
%
Do you inspect the trip lessors equipment
Yes
No
Do you require specific authorization before a driver may enter into a trip lease agreement?
Yes
Sunforest Transportation Insurance Group, Inc.
No
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Radius:
0 - 50 miles
Commodities:
%
% for each
201 – 500
51 - 200
%
Avg.Value
Max Value
%
501 - 1500
Commodities
%
% for each
%
%
%
%
%
%
%
%
1501+
Avg. Value
%
Max Value
Any hazardous commodities hauled such as chemicals, explosives, toxins, etc.? (If yes, please include percentage of each product):
Any Oversize/Overweight Commodities hauled? (If yes, please include percentage of each product):
Any Copper/Aluminum metals hauled?
(If yes, please include percentage of each product):
Does applicant transport high-value cargoes such as stereos, TVs, computer hardware, software or chips, pharmaceuticals, liquor, meat, seafood, etc.?
Yes
No
If yes, please describe commodity:
Method of Reporting:
Projected and
Historical
Information
MILEAGE
RECEIPTS
Policy Period:
Receipts:
UNITS
Miles:
OWNER OPERATOR
(Group Bobtail)
Total
Insured
Vehicle
Values
Units:
Historical
Deductible
APD:
Historical
Deductible
MTC:
Projected
Shipper 1 and Revenue
Shipper 2 and Revenue
%
%
%
Shipper 3 and Revenue
Is the Insured required to make financial responsibility filings (such as MCS-90 or other) for limits excess of underlying $1MM limits?
Yes
NO
If Yes, what do they transport that requires filings for limits in excess of $1MM?
DOT #:
MC#:
Has Any Insurance Company Cancelled or Non Renewed your policy in the last three years?
Yes
No
In the last three (3) years, has the applicant filed for or emerged from bankruptcy?
Yes
No
Auto Loss Experience (ground up and uncapped):
Policy Period:
# of Claims:
Paid:
Reserved:
Incurred:
Valued Date:
Attach details for all losses excess of $50,000. If any have penetrated in Excess layer, provide hard copy loss runs.
Sunforest Transportation Insurance Group, Inc.
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UNDERWRITING QUESTIONS
Are trailers left loaded and unattended in terminals or otherwise:
During the day?
Yes
No
How many?
Overnight?
Yes
No
How many?
If either answer is yes, give details of any security precautions taken to
secure the vehicle and cargo:
Are there any operations subject to seasonality?
YES
NO
Any Fuel Storage Facilities? ?
YES
NO
Any aircraft /watercraft exposure?
Yes
No
Do you sell any product on a wholesale or retail basis?
Yes
No
Do you derive any revenue from warehousing operations?
Yes
No
If you have your own authority:
Do you Lease/Hire Equipment from Others? If Yes, is it
Permanently Leased
Trip Leased
Is all owned or leased equipment scheduled on this application?
YES
NO
Is all equipment operated under the applicant’s authority scheduled on the application?
YES
%
NO
DRIVERS:
Written Safety Program
Yes
No
Comments:
Does this program include the incorporation of the following:
1.
Periodic safety meeting(s), documented?
2.
Written safety inspection program?
3.
Post accident drug testing?
4.
Is there an alcohol and drug rehabilitation program?
Is there a Driver Safety Incentive Program?
YES
NO
Explain:
Do you now or do you intend to hire owner operators?
YES
NO Current Number:
Do you agree to report all drivers?
YES
NO
Driver Turnover Percentage:
%
Percentage of drivers with less than 1 year with company:
%
Max/Min Age of Drivers:
/
Maximum # of moving violations allowed (last 3 years)
Maximum # of accidents allowed (last 3 years)
No. of Owner./Operators:
No. of Fleet Operators:
Are the owner/operators and/or fleet operators subject to the same rules and regulations as company drivers?
Yes
No
Do your driver selection procedures include:
Written application?
Yes
Road Test?
No
Yes
No
Reference checks?
Physical exam?
Pre-employment MVR review?
Yes
No
Yes
No
Yes
No
Prior employer contact?
Yes
No
Handling commodities?
Yes
No
Emergency procedures?
Yes
No
Written test?
Yes
No
Drug testing?
Yes
No
Does new driver training include:
Equipment familiarization?
Route familiarization?
Yes
Yes
Accident report procedures?
No
No
Yes
Length of new hire training program: _
No
Required for Owner/Operators?
Sunforest Transportation Insurance Group, Inc.
No
_.
Are new drivers assigned to drive with a senior, experienced driver?
Do you use drivers from training schools?
Yes
Yes
Yes
No
If yes, how long will they drive together? _
No If yes, describe the on-the-job training program for these drivers. _
_
_
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Coverages:
Limit:
Deductible
Auto Liability:
Non Trucking Liability
Leased to:
Uninsured Motorist
Underinsured Motorist
Medical Payments
Personal Injury Protection
Hired Auto Liability
Non Owned Liability
Additional Coverages?:
Cost of Hire:
Number of Employees:
Physical Damage Total Values
Comprehensive
Specified Perils
Collision
Hired Auto Physical Damage
Cargo
$
$
$
$
Deductible
Deductible
Deductible
Limit
# of days
# of units
Per Vehicle Limit
Per Catastrophe Limit
Per Terminal Limit
Deductible
Special Limit needed for:
Trailer Interchange Limit
Combined Deductibles
Reefer Breakdown
Rental Reimbursement
Wet Steel Coverage
Tarp Warranty
YES
YES
YES
YES
YES
# of days
NO
NO
NO
NO
NO
# of units
Trailer Interchange Agreement in Place?
YES
NO
GENERAL LIABILITY
General Liability Limit
Personal Injury/Advertising Liability (same as BI and PD limit):
Yes
No
Medical Payments
Fire Legal Liability
Insured’s Signature: _________________________________________________________________________________Date:
Sunforest Transportation Insurance Group, Inc.
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