CARGO ADD-ON SUPPLEMENTAL
This Supplement is a part of the Application and will
be relied upon by the Company as an integral part of
the Application.
1. APPLICANT'S NAME
2. Has any company ever cancelled or refused to issue cargo insurance? Yes No
If yes, explain
3. Have you purchased cargo insurance in the past 3 years? Yes No
PREVIOUS CARGO CARRIER AND LOSS EXPERIENCE (list for the past three years with most recent carrier first)
Policy Term
From To
Company & Policy Number Premium
Number of
Claims
Cause of Loss Amount Paid Reserves
4.
Type of Cargo % of Hauling Maximum Value Average Value
5.
6.
Applicant desires to have cargo premiums applied to each:
power unit
, which includes any trailers, semi-trailers, or mobile homes, but only while attached to a described power unit, or;
trailers
or semi-trailers.
7.
INSURANCE NEEDS – Complete for desired coverage.
Named Perils or Broad Form Deductible Amount $ Limit of Insurance $
OPTIONAL COVERAGES (additional premium): Additional Insured Endorsement (Lessee) Hired Car Cargo Coverage
Earned Freight Extension Limit
Other
REDUCTION OF COVERAGE (premium credit): Exclude Theft Coverage
If applicant hauls double wide mobile homes, limit of insurance must be equal to the value of both sides combined to satisfy co-insurance.
Amount of insurance on each truck should equal maximum load carried because the policy contains an 80% co-insurance clause
.
8.
CARGO FILING INFORMATION
List states for which insured requires CARGO FILINGS (check name on permits)
Is FHWA filing required? Yes No Docket Number
9.
MISCELLANEOUS
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
M-5717 FL (09/2012)
