Motor Truck Cargo Application
Agency:
Contact:
THE HARTFORD
marine
Phone:
Fax:
Risk Information:
Name:
Address:
Policy Period:
Motor Carrier Number:
Current Carrier:
Cancelled or Non-renewed?
YES
CORPORATION
SOLE OWNER
PRIVATE CARRIER
PARTNERSHIP
COMMON CARRIER
CONTRACT CARRIER
NO
PLEASE ATTACH A COPY OF THE EXISTING FILING.
Operates in following states:
Alabama
Arizona
Georgia
Maine
Nebraska
Ohio
Texas
Florida
Louisiana
Montana
N. Dakota
Tenn.
Arkansas
Idaho
Maryland
Nevada
Oklah.
Utah
California
Illinois
Mass.
N. Hamp.
Oregon
Vermont
Colorado
Indiana
Mich.
N.Jersey
Conn.
Iowa
Minnesota
N. Mexico
Penn.
R.I.
Virginia
Wash.
Wyom.
Kansas
Delaware
Kentucky
Missouri
N. Car.
S. Dakota
Wisc.
Miss.
N. Y.
S. Carl.
W. Vir.
BMC-34 eliminates the need for an individual state “intrastate” filing in all except those highlighted.
Operates in the following provinces:
Alberta
Ontario

British Columbia
P. E. I.
Manitoba
Quebec
Newfoundland
Nunavut
Nova Scotia
Radius of Operation:
Local(1-100 miles)

New Brunswick
Saskatchewan
% Intermediate(101-500 miles)
% Long Haul(500 + miles)
%
Principal Commodities Hauled (Theft Limitation may apply):
%
%
%
%
%
%
For whom does trucker haul primarily?
Gross Receipts (Past 5 Years):
Year
Receipts
Year
Receipts
$
Year
Receipts
$
Year
Receipts
$
Is trucker currently submitting financials to Central Analysis Bureau?
Yes
Year
Receipts
$
Date:
$
No
If no or more than 1 year from current date, please fax a current income statement and balance sheet to C.A.B. at: (212) 695-1618.

Premiums and Losses:
Please send five years hard copy loss experience; underwriter cannot proceed without this information.

Cargo Limits:
Per Vehicle
# Power Units:
$
Per Disaster
Owned
Deductible Requested:
Leased
$
Average Vehicle
Owner Op
$
# Trailers
# Refrigerated
$
Terminal Location(s):
Limit
$
$
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Signature of Applicant:
Date:
 2004 The Hartford, Hartford, CT 06115 df