Fillable CARRIER LOGISTICS CHOICE APPLICATION

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CARRIER LOGISTICS CHOICE APPLICATION

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The CARRIER LOGISTICS CHOICE APPLICATION form is 4 pages long and contains:

  • 2 signatures
  • 42 check-boxes
  • 99 other fields

Country of origin: OTHERS
File type: PDF

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APPLICANT INFORMATION
Insured Name:
Insured Street Address: City: State: Zip:
Agency Name:
Agency Code:
Producer Name:
Motor Carrier Number:
Insured’s Website Address:
Policy Period Eective Date: Expiration Date:
How many years has the insured been in business?
Has the insured’s Carrier’s Liability Coverage been cancelled or non-renewed in the past 3 years?
£
Yes
£
No
COVERED PROPERTY IN TRANSIT
List commodities hauled by % total of gross receipts. For commodities that aren’t listed use “Other” and provide a brief description.
CARGO | SUPPLEMENTAL APPLICATION
CARRIER LOGISTICS CHOICE APPLICATION
continued
COMMODITY % COMMODITY % COMMODITY %
Aircraft or watercraft Frozen foods Medical equipment
Auto parts, tires Furniture Dairy products
Beer General groceries/food stu Miscellaneous consumer products
Biological products-blood, organs Glass or glass products Miscellaneous industrial products
Bulk commodities Grain, seed, fertilizer Paper products
Chemicals Guns and ammunition Perfume and cosmetics
Cigarettes, tobacco products Hazardous material* Petroleum or petroleum products
Clothing Household goods Pharmaceuticals
Consumer electronics Jewelry, furs Precious metals
Fine arts or musical instruments Liquor, wine Textiles
Fresh fruit and vegetables Live animals Used equipment
Fresh meat, seafood, poultry Machinery or tools Vehicles, motor homes, campers
Other: Other: Other:
*Hazardous material is defined as a substance or material capable of posing an unreasonable risk to health, safety or property when transported in commerce.
Number of Units:
Annual Gross Receipts:
Annual Miles:
Motor Carrier Transit Limit:
Average Values Hauled per Conveyance:
Carrier’s Liability Deductible:
Radius of Operations: <50 Miles (Local): % 50-200 Miles (Intermediate): % >200 Miles (Long Haul): %
DRIVER SELECTION AND MANAGEMENT
What percentage of your drivers are “owner-operators”?
What percentage of your drivers are under the age of 25?
Do you have formal driver hiring and training procedures including pre-employment background checks and drug testing?
£
Yes
£
No
Do you have formal pre-employment and annual thereafter MVR review process including corrective action procedures?
£
Yes
£
No
Drivers prequalified for commodities hauled?
£
Yes
£
No
Regular review of SMS/CSA scores?
£
Yes
£
No
Does insured employ owner operators?
£
Yes
£
No
CARGO | SUPPLEMENTAL APPLICATION
CARGO SECURITY AND PROTECTION
Cargo protected by location tracking devices?
£
Yes
£
No
Do you review packing and handling procedures with your customers?
£
Yes
£
No
Do you utilize temperature monitoring systems?
£
Yes
£
No
If you haul hazardous materials, do you have a “HAZMAT” safe handling plan in place?
£
Yes
£
No
VEHICLE OPERATION AND MAINTENANCE
Does the insured operate refrigerated trailers?
£
Yes
£
No
Does the insured operate tandem/twin trailers?
£
Yes
£
No
Does the insured have a routine vehicle maintenance plan?
£
Yes
£
No
TERMINAL OPERATIONS Complete if applicable – add an additional sheet if needed.
Terminal 1 Terminal 2 Terminal 3
Address
Limit
Deductible
CONTINGENT COVERAGE FOR TRANSPORTATION BROKERS Complete if applicable.
For brokerage operations generating more than 25% of total gross receipts, please contact your underwriter.
Please attach a copy of the brokerage agreement.
Brokerage limit?
Annual brokerage receipts:
Check safety rating of subcontractors?
£
Yes
£
No
Check carrier’s authority on the FMCSA website?
£
Yes
£
No
Is the limit of liability on cert always equal or greater than shipment value?
£
Yes
£
No
Obtain copies of the subcontractors carrier liability insurance?
£
Yes
£
No
Does the insured call insurance company to verify coverage?
£
Yes
£
No
Do you issue bills of lading on behalf of the carrier?
£
Yes
£
No
COVERED PROPERTY IN STORAGE Complete if applicable.
Please attach a copy of the warehouse contract or warehouse storage receipt
Annual Gross Warehouse Receipts:
If Yes-Warehouse Legal Liability Limit:
ADDITIONAL LIMITS REQUIRED
Trailer Interchange Coverage-Increase Limit up to $50,000 Limit Requested $
Spoilage/Temperature Change-Increase to full limit
£
Yes
£
No
Rust/Corrosion/Contamination-Increase to full limit
£
Yes
£
No
LOSS HISTORY Please attach 5 year hard copy loss runs.
Year Gross Annual Receipts Total Losses Incurred Number of Losses
Prior Year
2nd Prior Year
3rd Prior Year
4th Prior Year
5th Prior Year
2
Knowingly presenting false or misleading information in an application for insurance may be a crime and violation of law subjecting the
applicant to criminal and civil penalties.
Arkansas, Louisiana, Rhode Island and West Virginia applicants: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
Alabama applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in
prison, or any combination thereof.
Colorado applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia applicants: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
Florida applicants: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
Kentucky applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
New Jersey applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
New Mexico applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma applicants: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application
or; (2) filing a claim containing a false statement as to any material fact may be violating state law.
Pennsylvania applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
FRAUD WARNING STATEMENTS
CARGO | SUPPLEMENTAL APPLICATION
3
Tennessee applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Virginia applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits.
Washington applicants: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Applicable to Utah applicants: If the policy will contain an arbitration clause: Any matter in dispute between you and the company may be subject to
arbitration as an alternative to court action pursuant to the rules of the (American Arbitration Association or other recognized arbitrator), a copy of which
is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award
may include attorney’s fees if allowed by state law and may be entered as a judgment in any court of proper jurisdiction.
SIGNING THIS FORM DOES NOT BIND THE APPLICANT FIRM OR THE COMPANY TO COMPLETE THE INSURANCE. APPLICATION MUST BE SIGNED
AND DATED BY AN OWNER, PARTNER OR OFFICER OF THE APPLICANT FIRM.
APPLICANT’S STATEMENT: I, being duly authorized, have read the above application and declare that to the best of my knowledge and belief all
of the foregoing statements are true, and that these statements are oered as an inducement to the Company to issue the policy for which I am
applying. (Kansas: This does not constitute a Warranty).
Authorized Signature:__________________________________________________  Title: _______________________________________________
Print Name: _______________________________________________________  Date: ______________________________________________
Producer’s Signature: _______________________________________________  Title: ______________________________________________
Print Name: _______________________________________________________  Date: _______________________________________________
License Identification Number or National Producer Number: ____________________________________________________________________
(Florida Producers must Provide License Identification Number)
First State Insurance Company New England Reinsurance Corporation
Hartford Accident and Indemnity Company Nutmeg Insurance Company
Hartford Casualty Insurance Company Omni Indemnity Company
Hartford Fire Insurance Company Omni Insurance Company
Hartford Insurance Company of Illinois Pacific Insurance Company, Limited
Hartford Insurance Company of the Midwest Property and Casualty Insurance Company of Hartford
Hartford Insurance Company of the Southeast Sentinel Insurance Company, Ltd.
Hartford Lloyd’s Insurance Company Trumbull Insurance Company
Hartford Underwriters Insurance Company Twin City Fire Insurance Company
New England Insurance Company
FRAUD WARNING STATEMENTS continued
CARGO | SUPPLEMENTAL APPLICATION
© 2018 by The Hartford. Classification: Personally Confidential for limited use only. All rights reserved.
No part of this document may be reproduced, published or used without the permission of The Hartford.
17-1385 © January 2018 TheHartford
Business Insurance
Employee Benefits
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ARBITRATION STATEMENT
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Completed 20 September 2021

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