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COMMERCIAL AUTO APPLICATION (Risk Placement Services, Inc.)

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RISK BOUND? YES NO DATE BOUND
TIME BOUND BROKER
INT.
COMMERCIAL AUTO APPLICATION
Producer:
Date Submitted:
APPLICANT INFORMATION:
Name:
Contact Name:
DBA:
Ma
iling Address:
Phone Number:
Fax Number:
List all garaging locations:
Insured is: Individual Partnership Corporation
Proposed Effective Date:
Federal Tax ID Number: Number of Years in Business:
Current Financials Attached? Yes No Have you ever filed for bankruptcy? Yes No
Ever operated under a different name? Yes No If yes, please provide name(s)
Do you have any Subsidiaries: Yes No If yes, please provide details of relationship:
DESCRIPTION OF OPERATIONS:
Carrier Type:
Common Contract Private Other
If Contract, for whom:
Description and scope of operations:
US DOT Number: MC Number: Latest DOT Rating: Yr.
State Filings Required? Yes No List State & State Cert #(s)
Have you been canceled/non-renewed by another carrier within the past three (3) years? Yes No
If yes, please provide details:
Is Carrier involved in any non-trucking business? Yes No
If yes, please complete the non-trucking application.
OWNERSHIP INFORMATION:
Name Position/Title # Years % Ownership
1.
2.
3.
4.
COMMODITIES HAULED (Show%)
% % %
% % %
% % %
% % %
% % %
Acceptance Indemnity Insurance Company
Acceptance Casualty Insurance Company
Occidental Fire & Casualty of North Carolina
Wilshire Insurance Company
Harco National Insurance Company
Transguard Insurance Company of America
- 2 -
SCOPE OF OPERATION:
Radius of operation:
Metro Areas? Yes No Delivery? Yes No Coastal? Yes No
Radius by %: 0-100 miles
101-300 miles 301-500 miles over 500 miles
Area(s):
East Coast Southeast Northeast Southwest Midwest West Coast Northeast
Average Trip by miles?
Maximum Trip by miles?
Largest Cities entered, list all traveled to or through:
EQUIPMENT OVERVIEW – Attach vehicle schedule
Type of Equipment Owned Owner/Operator Total # of units
Tractors
Heavy Trucks
Light Trucks/Vans
Service Units
Trailers
Spare Trailers
COVERAGES AND LIMITS
Application for:
Liability Physical Damage Motor Truck Cargo Other:
Basis of quote
Annual Receipts Mileage Monthly reporting Other:
Coverage to be Quoted
Liability Limits
Deductible Notes/comments
Truckers liability, Symbol
Bus. Auto liability, Symbol
UM/UIM Coverage
Trailer Interchange
Pip or Med Pay
Other:
Physical Damage
Collision Specified Perils Comprehensive
Deductibles:
Total Insured Value:
Comments:
Motor Truck Cargo
Commodity
Limit Deductible # of Units
Receipts/Mileage
Estimated annual receipts/mileage:
Additional Coverage Comments/Notes:
- 3 -
LOSS HISTORY
Previous Insurance and Loss Experience – This section must be completed in its entirety.
HARD COPY LOSS RUNS ARE REQUIRED
.
Auto Liability Current Prior Prior
Insurance Company
Policy number
Policy Dates
Total paid in Claims
Total in Reserve
# of Claims
Deductible
Premium
Loss Ratio
Physical Damage Current Prior Prior
Insurance Company
Policy number
Policy Dates
Total paid in Claims
Total in Reserve
# of Claims
Deductible
Premium
Loss Ratio
Cargo Current Prior Prior
Insurance Company
Policy number
Policy Dates
Total paid in Claims
Total in Reserve
# of Claims
Deductible
Premium
Loss Ratio
Description of any Losses over $25,000.00 or still open
1
2
3
4
5
6
7
8
9
10
- 4 -
Schedule of Units
Unit
No.
Symbol
Type
Model
Year
Make Stated
Value
Gross Vehicle
Weight
Complete
VIN
Loss Payee
& Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
PLEASE NOTE: If filings are required for this insured, ALL units owned &/or leased (including owner/operators) by this insured
MUST be scheduled and covered 100% of the time for this insured to be in compliance. Failure to do have all units on his/her policy
will result in an immediate cancellation of insured policy.
- 5 -
Driver Information
Name Date of
Birth
Driver’s License #
State License
Obtained
Years
Experience
Date of
Hire
# Accidents
Past 3 yrs
Traffic
Violations
Do you hire any drivers with less than 2 years CDL experience?
Yes No Minimum Experience Required?
Do you hire any part-time drivers?
Yes No
Do you check MVR before hiring a driver?
Yes No Drivers Drug tested prior to hire? Yes No
Random Drug test after hire? Yes No
Do you check Prior Employment? Yes No
# of Full Time Employee drivers?
# of Part-time Employee drivers?
# of Owner/Operators?
# of Team drivers?
- 6 -
My signature below indicates that I have reviewed this application, this list of drivers, this list of equipment and have
assigned the Stated Value (defined as actual value of equipment at the time of loss incurred) to each unit to be insured for
physical damage coverage. I am aware that the value of this equipment can vary with the current market place. I have
assumed responsibility for insuring only the equipment shown on this application.
I authorize IAT to obtain a copy of my Motor Vehicle Record for Rating/Underwriting the insurance for which I have
applied. I also understand that a routine inquiry may be made providing information concerning my character, general
reputation, personal characteristics and mode of living. Upon written request, information as to the nature and scope of
the report will be provided to me. I understand that misrepresentation or omission of material facts will be cause for
cancellation and may void coverage.
Printed name of Applicant Position/Title
Applicant’s Signature Date
Agent/Broker’s Signature Date
Any person who knowingly and with intent to defraud any insurance company or other persons 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.
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COMMERCIAL AUTO APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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