By Jerry Tucker,2014-06-26 18:55
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    102 Betsy Pack Drive, Jasper, TN 37347 (423) 942-1911 Phone / (423) 942-1988 Fax

    Email to:

Requested Effective Date:


    Exact Name and Address of Insured:

Garaging address if different:

    Phone: ( ) Facsimile ( )

    Person responsible for insurance:

    Email Address:

    Applicant is: Sole Proprietor Partnership Corporation

    USDOT# FEIN: ICC Docket # MC

    Is this how name appears on Auto Liability & Cargo Filings? Yes No

    Conducting business in present form since:


    Description and Scope of Operations:


What is your Base State:


     Atlanta % Denver % Los Angeles % Okla. City %

     Baltimore % Detroit % Louisville % Omaha %

     Boston % Hartford % Memphis % Philadelphia %

     Buffalo % Houston % Miami % Phoenix %

     Chicago % Jacksonville % Nashville % Pittsburgh %

     Cleveland % Kansas City % New Orleans % St. Louis %

     Dallas % Little Rock % New York % San Fran %

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    Extra Heavy Tractors Dry Van Trailers Heavy Tractors Refrigerated Trailers Heavy Trucks Flat Bed Trailers Medium Trucks Dump Trailers Light Service Trucks Tankers Single Axle Dump Trucks Intermodal Chassis Tri-Axle Dump Trucks Other

    Do you own any equipment not scheduled on this application? Yes No If Yes, explain:

    All equipment operating under your authority scheduled on this application? Yes No If No, explain:

    For Primary Liability, is unhooked coverage to be provided for scheduled Yes No trailers?

    If Yes, are trailers kept isolated from the public? Yes No If Yes, are trailers fully enclosed by a fence? Yes No


    Local Drivers Long Haul Drivers Local Owner/Operators Long Haul Owner/Operators

    Minimum Qualifying Age Company Drivers or Owner/Operators Maximum Qualifying Age Company Drivers or Owner/Operators

    Are All Owner/Operators under permanent lease to the Named Insured? Yes No Are All Company Drivers covered by Worker’s Compensation? Yes No Do you use teams? Yes No If Yes provide # of teams:

    How many drivers were hired during the past 12 months? How many drivers left your employ during the past 12 months?

    What is the minimum years of CDL experience mandated by the company?

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    The commodities hauled by the Insured principally consist of:

    Commodity Max. Value Avg. Value % of Total Apparel Inner, Outer or Footwear Appliances Auto Part / Tires Beverages Beer, Wine or Spirits Beverages Soft Drinks or Water Building Materials Canned Goods Computers / Parts / Peripherals Dry Freight Electronics Small Consumer Variety Electronics Large Consumer Variety Fish Fresh or Frozen Fragrances and Perfumes Frozen Food Housewares / Hardware Iron / Steel / Metal Juice or Juice Concentrate Paper / Paper Products / Printing Plastic / Plastic Products Produce Seafood Fresh or Frozen Tiles Roofing, Flooring or Decorative Tobacco or Tobacco Products Other Other Other

Coverage for Target Commodities varies by insurance carrier and may be limited, restricted or otherwise

    excluded under the policy form. Failure to specify Target Commodity exposures may result in exclusion of

    coverage. Target Commodities shall mean all consumer and commercial goods, including but not limited

    to; electrical appliances or instruments and any other audio/video-related equipment, Computers;

    including all internal or external parts, chips, peripherals, monitors or other components, Wearing

    Apparel, both innerwear or outerwear, including footwear, Seafood (fresh or frozen) including shellfish,

    Perfumes and Fragrances, Alcohol, Tobacco and Tobacco related products.

    Do you haul Hazardous Materials? Yes No

    If Yes, explain:

    Do any of your loads require placards? Yes No

    If Yes, explain:

    Page 3 of 8 6/26/2010 6:55 PM

    Do any of your loads require temperature control? Yes No

     If Yes, explain:

    If Yes, are refrigeration units serviced regularly: Yes No If Yes, are units serviced by a Certified Technician: Yes No If Yes, are service records maintained: Yes No Any Oversize/Overweight Operations? Yes No If Yes, explain:

    Any operations require specialty equipment or tarpaulins? Yes No If Yes, explain:

    Are Drivers engaged in Loading or Unloading operations? Yes No If Yes, explain:


    Normal Hours of Operation: From: To: Premises Supervised During These Times? Yes No If No, When Supervised? From: To: Is Security Provided After Hours? Yes No Is Premises Lighted? Yes No Is the premises Gated? Yes No Are Any Trailers/Containers Left Loaded Overnight? Yes No If Yes, State % of Loads Weekly:


    Period Gross Revenue Mileage Number of Units

    Projected Exposures for Coming Policy Year


    Radius Percentage Number of Power Units > 50 Miles 50 to 200 Miles 201 to 500 Miles < 500 Miles Average Length of Haul:

    Maximum Length of Haul:

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    Driver Qualification, Selection and Administrative Procedures:

    Written Application? Yes No Prior Employment References? Yes No Road Test including familiarization with route and equipment? Yes No Written test including familiarization with company guidelines? Yes No Pre-Employment Screening and Drug Testing? Yes No Are complete files maintained in accordance with DOT guidelines? Yes No Does driver administration include physical examination? Yes No If Yes, are these examinations reviewed Pre-employment? Yes No Is there periodic review of examinations for current drivers? Yes No If, Yes, how often?

    Are MVR’s reviewed for potential new drivers? Yes No Are MVR’s reviewed periodically for existing drivers? Yes No How often are MVR’s reviewed?

    By whom are MVR’s reviewed?

    Are drivers provided written guidelines for operations and safety? Yes No Is there a formal post-accident review procedure in place? Yes No Does this procedure include potential suspension or termination? Yes No Are Safety Meetings held? Yes No If Yes, how often?

    How are drivers compensated?

    Are there daily inspection procedures? Yes No Are there written emergency and accident reporting procedures? Yes No Is there road patrol by management? Yes No Is there road supervision using GPS or similar tracking devices? Yes No Are drivers radio dispatched? Yes No Are Trucks equipped with any type of speed regulators/limiters? Yes No


    Are Driver Log books used? Yes No Are they reviewed by management? Yes No Are there Penalties for violation? Yes No Is a Daily call-in system used? Yes No Are Predetermined truck stops used? Yes No

    Page 5 of 8 6/26/2010 6:55 PM


    Records kept of each vehicle with controlled inspection frequency? Yes No Daily vehicle condition reports? Yes No Front axle brakes operative on all units? Yes No Does Insured service vehicles? Yes No If yes, number of mechanics

    If no, are certified service facilities used? Yes No


    COVERAGE CARRIER EFFECTIVE POLICYLIMITS ANNUAL PREMIUM AUTO LIABILITY Is AL policy Monthly Reporting, Direct Bill or Premium Financed? PHYS. DAMAGE Is APD policy Monthly Reporting, Direct Bill or Premium Financed? CARGO Is MTC policy Monthly Reporting, Direct Bill or Premium Financed?

DESIRED COVERAGES: Specify coverage and limits below:

    AUTO LIABILITY Deductible Basis

     CSL Split Limits Primary Auto Liability

     CSL Split Limits Personal Injury Protection

     CSL Split Limits Uninsured Motorists

     CSL Split Limits Medical Payments

     CSL Split Limits Non-Owned Auto Liability

     CSL Split Limits Hired Auto Liability


    Total Stated Values

    Total Stated Values - Tractors

    Total Stated Values Trailers

    Deductible Each Loss

    Coverage Form Comprehensive & Collision Specified Perils

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    MOTOR TRUCK CARGO Broad Form including Earned Freight, Debris Removal & Theft Limit - Per Conveyance Limit - Per Occurrence Limit - Specified Terminal Specified Shipper(s)? Yes No If Yes, detail in section below

    Refrigeration Breakdown? Yes No Deductible - Each Claim Theft Deductible - Each Claim


    #1 - Name of Shipper Specified Limit #2 - Name of Shipper Specified Limit #3 - Name of Shipper Specified Limit Note: If total exposure is >10%, carrier may not provide a different Limit Per Conveyance for Specified Shippers.


    Terminal #1 Limit Terminal #2 Limit Terminal #3 Limit Terminal #4 Limit Note: Coverage for Scheduled Terminals is subject to details of Security Protocols at each requested location


    Limit Per Conveyance Deductible - Each Claim Number of Days Number of Units Increased Limit for Specified Shipper(s)? Yes No If Yes, detail in section below

    SPECIFIED SHIPPERS INTERCHANGE COVERAGE #1 - Name of Shipper Specified Limit #2 - Name of Shipper Specified Limit #3 - Name of Shipper Specified Limit

    Has any company during the past 3 years, cancelled or non-renewed your insurance? Yes No If Yes, explain:

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    The applicant hereby applies to the company for a policy(s) of insurance as set forth in this application

    on the basis of statements contained herein. Applicant agrees that such policy(s) shall be null and

    void if such information is materially false or misleading so that the company would have rejected the

    risk. Applicant understands that an inquiry may be made which will provide applicable information

    concerning character, general reputation, financial stability and other pertinent financial data, or

    other background information the company deems necessary in order to determine whether to accept

    or reject the applicant for coverage. Upon written request, additional information as to the nature and

    scope will be provided.

    Signed this Day of 20

    Signed at:

    City & State

    Signed by:

    Authorized Representative of the Named Insured


Signed this Day of 20

    Signed at:

    City & State

    Signed by:

    Authorized Representative of Truck Insurance Group, LLC


    Page 8 of 8 6/26/2010 6:55 PM

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