Fillable CARGO SUPPLEMENTAL APPLICATION 03 16 CC 972 (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank CARGO SUPPLEMENTAL APPLICATION 03 16 CC 972 (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CARGO SUPPLEMENTAL APPLICATION 03 16 CC 972 (Risk Placement Services, Inc.)

On average this form takes 29 minutes to complete

The CARGO SUPPLEMENTAL APPLICATION 03 16 CC 972 (Risk Placement Services, Inc.) form is 2 pages long and contains:

  • 3 signatures
  • 14 check-boxes
  • 99 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CC 972
03 16
CC 972
03 16 Page 1 of 2
CARGO SUPPLEMENTAL APPLICATION
(must be submitted with Commercial Auto Brokerage App)
GENERAL
Applicant’s Name:
DOT / MC #
Show name exactly as it appears on
Regulatory Authority Permits
Mailing
Address:
Street
City
State
County
Contact for Safety Inspection
(Name & Phone):
Effective Date:
Expiration Date:
Property hauled
Owned
Property of Others
TYPE OF PROPERTY HAULED: Avoid such terms as “general merchandise.” State approximate percentage of maximum load value.
Type of Cargo % of Hauling Maximum Value
COVERAGE
Limit Requested:
Deductible:
Additional Coverages:
Temperature Control Equipment Breakdown (Minimum $2500 deductible required)
Terminal Coverage
IF TERMINAL COVERAGE IS DESIRED, COMPLETE THE FOLLOWING OR ATTACH LIST.
Location Address
Building Construction
Security
Limit
Deductible
Do you haul any hazardous, flammable, explosive, corrosive or chemical materials?
Yes
No
If yes, please give name, class, and number of loads per week:
Do you haul any of the following high theft commodities: electronics, drugs & pharmaceutical
products, liquors or beverages exceeding 10% alcohol content, cigarettes, cigars or other
finished tobacco products, furs or garments trimmed in fur or copper & copper products?
(If yes, please note coverage is limited to 10% of the loss)
Yes
No
Do you have shippers requiring higher limits than maximum cargo values indicated above?
Yes
No
Shipper Name:
Commodity
Specify Limit:
% of loads
Any Oversize / Overweight Loads Hauled?
Yes No
Please List Current Shipper Contracts:
PROTECTION
Number of persons on trucks
Are bodies of all trucks and trailers completely closed and equipped with snap locks?
Yes
No
Are loaded trucks ever left unattended or trailers unattached?
Yes
No
If yes, explain
What security is provided for loaded vehicles? (Check all that apply)
At Locations:
Fenced Lot
Security Guards
In a Locked Building
Building Theft Alarm
Lighted
Kingpin Locks
In Transit:
Lojack or GPS device
Vehicle Theft Alarm
Kingpin Locks
Other (describe)
CC 972 03 16
CC 972 03 16 Page 2 of 2
LOSS HISTORY
Policy Year
Carrier
Premiums
Paid Losses
Reserves
No. of Claims
Current Year
Prior Year
Next Prior Year
3
rd
Prior Year
THE COVERAGES REQUESTED IN THIS APPLICATION ARE SUBJECT TO A MINIMUM EARNED PREMIUM OR BINDER
PREMIUM OF $500.00.
PRIVACY NOTIFICATION: PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT OR OTHER
INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR
INSURANCE AND SUBSEQUENT RENEWALS. ANY INFORMATION WHICH WE HAVE OR MAY OBTAIN ABOUT YOU OR OTHER
INDIVIDUALS LISTED AS POLICYHOLDERS ON YOUR POLICY WILL BE TREATED CONFIDENTIALLY. SUCH INFORMATION AS WELL
AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES
BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION FOR SUCH PURPOSES AS CLAIMS HANDLING, SERVICING,
UNDERWRITING AND INSURANCE MARKETING. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES
AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR
PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR
INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM FOR PAYMENT OF A LOSS OR BENEFIT CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH MAY BE, OR IN SOME STATES IS, A CRIME AND SUBJECTS THE
PERSON TO CRIMINAL AND CIVIL PENALTIES. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE
BENEFITS.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL
APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
APPLICANT AGREES to furnish, promptly, driver data for every driver engaged during the policy period. Applicant, Agent or Broker
understand and agree that no flat cancellation will be allowed. Agent and/or Broker guarantee payment of earned premium to final
termination date of policy or of any filing made by the company on behalf of the Applicant.
COVERAGE HAS NOT COMMENCED. You, or your agent, may commence coverage only by requesting a licensed general agent of
Carolina Casualty / Great Divide Insurance Company to bind coverage. A binder of insurance will be issued by our licensed general
agent specifying the date and time coverage will become effective, but in no event shall coverage become effective prior to the date and
time you, or your agent, contact a licensed general agent of Carolina Casualty Insurance Company and coverage is bound by him or
her.
SIGNATURES
I understand this application is not a binder and that binding must be made by an Authorized Licensed Representative of Carolina Casualty / Great
Divide Insurance Company.
Signature of Producing Agent
I hereby authorize Carolina Casualty / Great Divide Insurance Company and/or the Producing Agent to obtain from the proper authority a copy of my
Motor Vehicle Report and or Credit Report for use in rating and/or underwriting the insurance for which I do hereby apply and any renewal thereof.
I hereby represent that the named drivers under this policy (names specified on application and/or drivers hired during the term of this insurance) have or
will have authorized me to consent on their behalf for the insurer to obtain Motor Vehicle Reports for rating and/or underwriting.
I have read this application and all of the responses are mine and not supplied by the producer, agent or company.
I hereby represent that the information contained in this application is true.
Date Application
Completed
Name & Address
Of Agent
Applicant’s Signature
Agent Registration #
Licensed Agent of the Company
Agent Phone Number
Licensed Agent ID#
Agent Signature
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CARGO SUPPLEMENTAL APPLICATION 03 16 CC 972 (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document