Name Your Preferred RPS Underwriter:
________________________________________________________
CARGO / PHYSICAL DAMAGE
PROPOSAL
SURVEY FOR INSURANCE
PROPOSAL
MUST BE COMPLETED AND SIGNED FOR QUOTATION TO BE
TENDERED
Effective:
2.
Address- Terminal locations
if more than
one.
3.
Business is:
Common Carrier
No. years in
business
Contract Carrier
Private Carrier (Owner's
goods on own
vehicle.)
4. Owner’s Name:
5. MC#: DOT#:
6.
Operates
in States or
Provinces of:
7.
Routes (List All Major Cities Entered)
:
8.
Type of Operation: (Select All That Would Apply)
___Dry Van ___Reefer ___Flatbed ___Container ___Auto Hauler ___Other:Explain _______________________________
9. Do you own or use equipment other than that listed above?
No
Yes,
Details:
10. Do you lease, loan or rent any of your equipment to others?
No
Yes,
Details:
11. Name of present insurance carrier(s)
and Policy No.(s)
12. Has
Physical Damage or Cargo coverage been cancelled or non renewed in
the past 3 years?
Yes
No
Details:
13a. Cargo Limits Requested:
Exposure per
Vehicle
Exposure per
Vehicle
13b. Cargo Deductible Requested:
Present Insuring Conditions:
Form & Deductible Requested:
13c. Phy Dmg Deductible Req:
Present Insuring Conditions:
Form & Deductible Requested:
14. Is
terminal coverage required?
If yes, please list details on page 2
15. Is liquor or manufactured tobacco transported? If yes, give details separately
16.
Experience- Current
and Past Three Years: FLEETS ATTACH LOSS RUNS. IF MULTIPLE LOSSES
-ITEMIZE
Premium
Clms
Losses
Paid and
Outstanding
17.
DETAILS
OF
LARGE LOSSES:
