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Cargo - Motor Truck Cargo Proposal (Strickland Insurance Brokers)

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Lloyds MTC 2012
1
Phone # 888
-
495
-
4950
Fax # 888-997-9970
Motor Truck Cargo Proposal P.O. Box 8010
Goldsboro, NC 27534
GENERAL INFORMATION
Agent Name, Street, and City
State
Telephone
Applicant Name/DBA
Telephone
Desired Policy Period
TO
Business Address/Street, City
State
Zip Code
Years in Business
Garage Address/Street, City
State
Inspection Contact Name
Telephone
Insured is
Corporation
Partnership
Individual
Are others Leased to Applicant?
Yes No If yes, Permanent Lease Trip Lease
Is Applicant Leased to others?
Yes No If yes, to whom?
Commodities hauled by % including Values
States and Cities Entered:
% of Round Trips by Radius (in Miles)
<301 301-500 501-1500 >1500
FREQUENTLY TRAVELED METRO AREAS
ATLANTA BALT/WASH. DC BOSTON CHICAGO DALLAS/FT.WORTH
DETROIT HARTFORD HOUSTON LOS ANGELES MIAMI
NY CITY PHILADELPHIA SAN FRANCISCO NEWARK/ NJ
COVERAGE INFORMATION
DOES APPLICANT HAVE A BROKERAGE OPERATION? Yes No If Yes, ICC Brokerage #
Est. Brokerage Revenue:
CARGO All Risk Named Peril
Catastrophe Limit Terminal Limit Deductible:
Terminal Location: Refrigeration Breakdown: Yes No (min. Deductible $2,500)
INSURANCE CARRIER & LOSS INFORMATION – PAID AND RESERVE – THREE YEAR MINIMUM
POLICY PERIODS
COMPANY AND POLICY NUMBER CARGO
FROM TO
HAS APPLICANT EVER HAD TRUCK INSURANCE CANCELLED OR NON-RENEWED Yes No If yes , give details
FILING INFORMATION – CARGO
ICC DOCKET #: MC#
Base State: Intrastate/Exempt Filing(s) Required:
Do you require cover for cargo in terminals or at other places where vehicles are often left
overnight or at weekends either on vehicles______________? or off vehicles ______________?
If either answer is yes, please give details of any such places which are regularly used:
Address
Fenced yard locked at night? Yes No 24 hour watchman? Yes No Alarmed Building? Yes No
Sprinklered Building? Yes No Max. value exposed?
Lloyds MTC 2012
2
Phone # 888
-
495
-
4950
Fax # 888-997-9970
Motor Truck Cargo Proposal P.O. Box 8010
Goldsboro, NC 27534
EQUIPMENT INFORMATION
#
YEAR
MAKE
TYPE
CARGO LIMIT
DEDUCTIBLE
VEHICLE IDENTIFICATION NUMBER
RADIUS
1.
2.
3.
4.
DOES APPLICANT OWN/LEASE ANY OTHER POWER UNITS? Yes No If Yes, give details:
DRIVER INFORMATION ------ ATTACH MVR FOR EACH DRIVER ------
Name
Date of
Birth
State License Number
Years
Exp.
MVR Violations last 36 Month
1.
2.
3.
4.
The following interests are excluded, but can normally be covered at additional premium if requested. Accounts, bills, debts, evidence of debt,
letters of credit, passports, documents, railroad or other tickets, notes, money, securities, currency, bullion, precious stones, jewelry &/or other
similar valuable articles, paintings, statuary and other works of art, manuscripts, mechanical drawings, live animals, tobacco, cigars, cigarettes,
non-ferrous metal in scrap or ingot form, furs, alcohol, liquor, beer, wine, garments (defined as: items of clothing, including innerwear and
outerwear, footwear, shoes, boots, gloves, hats, and the like), seafood unless canned, and electronics (defined as: all items of consumer and
commercial electrical appliances and instruments including but not limited to radios, stereos, televisions, computers, computer software, hard
drives, chips, modems, monitors, cameras, facsimile machines, photocopiers, VCRs, hi-fis, CD players and the like. Note: Heavy electrical
items, such as switchgear, turbines, generators and the like are NOT considered to be electronics).
I authorized_______________________ and/or the producing agent to obtain proper cop(ies) of my Motor Vehicle Report for insurance
underwriting purposes. As well, any additional drivers listed and/or any drivers who will operate equipment covered under any prospective
insurance policy for which this application relates have or will have authorized me to consent the same. I certify that all application information
is true and agree that any misrepresentation by me will constitute reasons for the company to void or cancel any policies issued on the basis of
this application, and will hold the company harmless for the action taken.
Sig
nature of Applicant: ___________________________ Date: ___________ Signature of Agent:___________________________ Date: __________
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POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM
INSURANCE COVERAGE
You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you
now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in
Section 102(1) of the Act, as amended: The term "act of terrorism" means any act that is certified by the
Secretary of the Treasury, in consultation with the Secretary of Homeland Security and the Attorney General of
the United States, to be an act of terrorism; to be a violent act or an act that is dangerous to human life,
property, or infrastructure; to have resulted in damage within the United States, or outside the United States
in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed
by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to
influence the policy or affect the conduct of the United States Government by coercion. Any coverage you
purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2020, the date on which the TRIA
Program is scheduled to terminate, or the expiry date of the policy whichever occurs first, and shall not cover
any losses or events which arise after the earlier of these dates.
YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF
TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL
LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE,
SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 85%
THROUGH 2015; 84% BEGINNING ON JANUARY 1, 2016; 83% BEGINNING ON JANUARY 1, 2017; 82%
BEGINNING ON JANUARY 1,2018; 81% BEGINNING ON JANUARY 1, 2019 AND 80% BEGINNING ON JANUARY 1,
2020; OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE
INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE
ACT, AS AMENDED, CONTAINS A USD100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS
WELL AS INSURERS LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE
AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS USD100 BILLION. IF THE AGGREGATE
INSURED LOSSES FOR ALL INSURERS EXCEED USD100 BILLION, YOUR COVERAGE MAY BE REDUCED.
THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES
FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.
I hereby elect to purchase coverage for acts of terrorism for a prospective premium of
USD………………….
I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand that I
will have no coverage for losses arising from acts of terrorism.
Policyholder/Applicant's Signature Syndicate on behalf of certain underwriters at Lloyd's
Print Name Policy Number Date
LMA9104
12 January 2015
_________________________
_________________________________________________________________________________
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Cargo - Motor Truck Cargo Proposal (Strickland Insurance Brokers)

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Completed 17 July 2021

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