Canal Truck Renewal/Anniversary Update Form
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
REN-101 Page 1 of 2 (Rev. 11-2009)
Insured Legal Name Current Policy Number
Renewal Date Tax Identification Number / Social Security Number DOT Number
Indicate Policy Term and Payment Method
Annual Policy Continuous Until Cancelled Policy (2 month escrow deposit and monthly billing)
Financed through outside Premium Finance Company with full payment to Canal (no double financing permitted – attach contract)
Full Payment to Company Company Payment Plan
Have there been any changes to any of the following?
Yes No Company Name or Insured’s Legal Name Yes No Commodities Transported
Yes No Physical Address or Garaging Location Yes No Maximum Radius Hauled
Yes No Business Class or Operations Yes No Area of Operations
Please explain all “Yes” answers
It is only necessary to complete the following for Cargo and Auto Liability: Canal requires all owned, leased and operated units to be
scheduled when an MCS-90 or filings are issued. Are all owned, leased and operated equipment scheduled on the policy?
Yes No If no, please explain
It is only necessary to complete the following for Auto Liability: Are all drivers scheduled on the policy?
Yes No If no, please explain
If there are any changes from the original application please indicate below. If not, please leave the coverage selections blank.
Coverages Desired:
Auto Liability Auto Physical Damage Motor Truck Cargo Truckers General Liability
Auto Physical Damage Coverage Selection
Deductible Desired Coverage Desired
$500 $1,000 $2,500 $5,000 Collision and Specified Causes of Loss Collision and Comprehensive (where available)
Additional Auto Physical Damage Coverages Desired
Additional Towing Limit $ (in the event of a total loss to the described unit) $2,500 included
Trailer Interchange Limit $ Minus $1,000 Deductible (UIIA container haulers)
Non-Owned Trailer Limit $ Minus $1,000 Deductible (coverage applies only while attached to a scheduled power unit)
Motor Truck Cargo Coverage Selection
Please select the desired form: Standard Preferred
Limit Desire Per Vehicle $ Deductible Desired $500 $1,000 $2,500 $5,000
Units that require specific limits other than above, please indicate below.
Unit No. Desired Limit Unit No. Desired Limit
$ $
Additional Cargo Coverages or Endorsements Desired
Refrigeration Breakdown - $2,500 minimum deductible required Removal of Coinsurance Clause Removal of Commodities Theft
Earned Freight Increase to $ ($1,000 included) Debris Removal Increase to $ ($25,000 included)
Loss Mitigation Increase to $ ($7,500 included) Reusable Packing Container Increase to $ ($5,000 included)
Truckers General Liability Coverage Selection
Desired Limits General Aggregate - please select one $1,000,000 $2,000,000 Each Occurrence $1,000,000 (included)
Employers Liability (Stop Gap) Coverage - Applicable only in ND, OH, WA and WY. Please select either Yes or No.
Yes No $1,000,000 Bodily Injury by Accident - each accident $1,000,000 Bodily Injury by Disease - each employee
$1,000,000 Bodily Injury by Disease - each policy
Please indicate any additional changes not listed above:
Auto Liability Coverage Selection
Combined Single Limit - each accident $
If applying for Hired Auto coverage, please enter the annual estimated cost of hire:
If Non-Owned coverage is desired please enter the number of employees:
Is this a social service agency or charitable organization? Yes No
