Fillable Form 3: Transportation Truckers Supplement 2 1 Terminal (Risk Placement Services, Inc.)

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Form 3: Transportation Truckers Supplement 2 1 Terminal (Risk Placement Services, Inc.)

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# of
y
ears in business Website
Current excess carrier Limi
t
Premium
1
2
3
4
5
Radius of O
p
erations
Le
g
al name of brokera
g
e entit
y
if different from named insured -
MC Carrier number for brokera
g
e
Revenue
g
enerated from brokera
g
e
Use of an
y
sub-haulers?
Cost of hire of sub-haulers
Do
y
ou have brokera
g
e authorit
y
?
Owner O
erator
Commodit
y
Information
3rd Prior Year
4th Prior Year
Revenue Units
Revenue
Pro
j
ected and Historical Information
Period
Pro
j
ected
Current
1st Prior Year
2nd Prior Year
Radius
0 to 50 miles
Percenta
g
e
Re
g
ular route
Irre
g
ular route
Sli
p
seat or Multi
p
le shifts
Milea
g
e
Terminal Locations
Li
g
ht Trucks
PPT
DOT #:
Trailers
E
q
ui
p
ment Owned
Tractors
Xhv
y
Trucks
Heav
y
Trucks
Medium Trucks
Cit
y
:
Zi
p
:
5th Prior Year
MC #:
%
%
Brokera
g
e/Sub Haul
Transportation
Truckers Supplement
INSURED INFORMATION
Com
p
an
y
Name: Effective Date:
Number of units @ each location
www.
State:
Team drivers
201 to 500 miles
501+ miles
Do
y
ou haul an
y
hazardous materials?
List the hazardous material classes that
y
ou haul:
Do
y
ou have a emer
g
enc
y
res
p
onse
p
lan in
p
lace?
51 to 200 miles
What is
y
our avera
g
e len
g
th of haul?
What is
y
our maximum len
g
th of haul?
What filin
g
s are re
q
uired?
Percenta
g
eT
yp
e
Driver Turnover %:
Safet
y
Manual:
Safet
y
Incentive Pa
y
:
Safet
y
Meetin
g
s: Fre
q
uenc
y
:
Driver files are all current and com
p
lete
Drivers hired in
p
ast 12 months/total drivers
Cell
p
hone
p
olic
y
Passen
g
er
p
olic
y
,
p
assen
g
er accident insurance, hold harmless a
g
reements
Load Securement Trainin
g
Driver selection
p
rocedures with written a
pp
lication,
p
rior em
p
lo
y
ment checks, reference checks
Written maintenance
p
ro
g
ram in
p
lace with tractor and trailer ins
p
ections on a re
q
ular fre
q
uenc
y
Pre and
p
ost tri
p
ins
p
ections
E
q
ui
p
ment maintenance files ke
p
t for each vehilce and accurate/com
p
lete
If a
pp
licable, Owner O
p
erators follow same maintenance
p
ro
g
ram
Safet
y
Mana
g
er:
(
Monthl
y
, Quarterl
y
, Annuall
y)
Y
ears of Ex
p
erience:
Lo
gg
in
g
p
rocedures and driver lo
g
reviewin
g
b
y
mana
g
ement,
p
enalties for violation
s
Maintenance
% of Use % of Use
O/O E
q
ui
p
Road test, written test certifications
A
ccident investi
g
ation and driver disci
p
linar
y
, retrainin
g
p
rocedures
Substance abuse,
p
re em
p
lo
y
ment testin
g
, random testin
g
TECHNOLOGY
Telematics, Vendor Name:
Govenors, What speed:
Electronic Logs
GPS Tracking
Roll Stability Control
Systems Anti-lock Braking
Blind Spot Warning Adaptive
Cruise Control Lane
Departure Warning Collision
Avoidance Systems Side and
Rear Cameras Video Event
Recorder
In-cab Navigation System
Com
p
an
y
E
q
ui
p
Ph
y
sical examinations,
p
re
p
lacement,
p
eriodicall
y
SAFETY / DRIVER / MAINTENANCE INFORMATION
Driver Hiring & Indoctrination
Safet
y
Awards:
Are Owner Operators subject to the same standards as company drivers
Minimum Driver Age:
Maximum Driver Age:
- Formal Safety Program:
V
ideo Event Recorde
r
In-cab Navi
g
ation S
y
stem
Collision Avoidance S
y
stem
s
Side and Rear Camera
s
A
da
p
tive Cruise Control
Lane De
p
arture Warnin
g
A
nti-lock Brakin
g
Blind S
p
ot Warnin
g
GPS Trackin
g
Roll Stabilit
y
Control S
y
stem
s
Govenors
,
What s
p
eed:
Electronic Lo
g
s
Com
p
an
y
E
q
ui
p
O/O E
q
ui
p
Telematics
,
Vendor Name:
If a
pp
licable
,
Owner O
p
erators follow same maintenance
p
ro
g
ra
m
TECHNOLOGY
% of Use % of Use
Maintenance
E
q
ui
p
ment maintenance files ke
p
t for each vehilce and accurate/com
p
let
e
Written maintenance
p
ro
g
ram in
p
lace with tractor and trailer ins
p
ections on a re
q
ular fre
q
uenc
y
Pre and
p
ost tri
p
ins
p
ection
s
Maximum Driver A
g
e:
Driver Turnover %:
Passen
g
er
p
olic
y,
p
assen
g
er accident insurance
,
hold harmless a
g
reement
s
Load Securement Trainin
g
A
ccident investi
g
ation and driver disci
p
linar
y,
retrainin
g
p
rocedure
s
Minimum Driver A
g
e:
Substance abuse
,
p
re em
p
lo
y
ment testin
g,
random testin
g
Ps
y
cholo
g
ical testin
g
Driver files are all current and com
p
let
e
Formal return-to-work
p
ro
g
ram
Lo
gg
in
g
p
rocedures and driver lo
g
reviewin
g
b
y
mana
g
ement
,
p
enalties for violation
s
Cell
p
hone
p
olic
y
Driver Hirin
g
& Indoctrination
Driver selection
p
rocedures with written a
pp
lication
,
p
rior em
p
lo
y
ment checks
,
reference check
s
Road test
,
written test certification
s
Ph
y
sical examinations
,
p
re
p
lacement
,
p
eriodicall
y
Safet
y
Awards:
Safet
y
Meetin
g
s: Fre
q
uenc
y
:
(
Monthl
y,
Q
uarterl
y,
Annuall
y)
Safet
y
Manual:
Safet
y
Incentive Pa
y
:
SAFETY / DRIVER / MAINTENANCE INFORMATION
Safet
y
Mana
g
er: Years of Experience: - Formal Safet
y
Pro
g
ram:
Cit
y
:
Zi
p
: DOT #:
State: MC #:
TRANSPORTATION
SAFETY & TECHNOLOGY
INSURED INFORMATION
Com
p
an
y
Name: Effective Date:
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Form 3: Transportation Truckers Supplement 2 1 Terminal (Risk Placement Services, Inc.)

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Completed 30 July 2020

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