Fillable Form 4.: SUPPLEMENT TO TRUCK APPLICATION CARGO COVERAGE (Risk Placement Services, Inc.)

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Form 4.: SUPPLEMENT TO TRUCK APPLICATION CARGO COVERAGE (Risk Placement Services, Inc.)

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SUPPLEMENT TO TRUCK APPLICATION
CARGO COVERAGE APPLICATION
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) Loading and Unloading Coverage
Earned Freight Coverage Refrigeration Breakdow
n Coverage Hired Car Cargo Coverage
REDUCTION OF COVERAGE (premium credit): Exclude Theft Coverage
If applicant hauls double w
ide 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, as policies contain 100% co-insurance clause.
8.
CARGO FILING INFORMATION
List states for which insured requires CARGO FILINGS (check name on permits)
Is I.C.C. filing required? Y
es No I.C.C. Docket Number
9.
MISCELLANEOUS
Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
M-4413b PA (04/2010)
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Form 4.: SUPPLEMENT TO TRUCK APPLICATION CARGO COVERAGE (Risk Placement Services, Inc.)

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Completed 23 November 2020

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