Fillable Form 5.: Cargo Application COLUMBIA INSURANCE COMPANY Business (Risk Placement Services, Inc.)

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Form 5.: Cargo Application COLUMBIA INSURANCE COMPANY Business (Risk Placement Services, Inc.)

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Name (and "dba")
Individual/Proprietorship Partnership Corporation Other
Cargo Application
COLUMBIA INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY
NATIONAL FIRE & MARINE INSURANCE COMPANY
NATIONAL LIABILITY & FIRE INSURANCE COMPANY
NATIONAL INDEMNITY COMPANY OF THE SOUTH
NATIONAL INDEMNITY COMPANY OF MID-AMERICA
Policy Term From:
To:
1.
Business Phone Number
2. Premises Address City State Zip
3. Garaging Address City State Zip
4. Person to Contact for Inspection (name and phone number)
5.
Have you ever had insurance with one of the companies listed at the top of this page? Yes No
If yes, policy number(s)
Effective Date(s)
DESCRIPTION OF OPERATIONS
6. Describe Business
Years Experience
New Venture? Yes No
7.
Is this your primary business? Yes No
If no, explain
Seasonal? Yes No
8.
Have you ever filed for bankruptcy? Yes No
If yes, when Explain
9. Gross Receipts Last Year
Business for sale? Yes No
10.
Do you haul for hire? Yes No
11.
Are you a common carrier? Yes No
Estimate for Coming Year
Show largest cities entered
Are you a contract hauler? Yes No If yes, for whom
12.
Do you haul your own cargo exclusively? Yes No
If not, who owns it?
13.
Do you pull double trailers? Yes No Triple trailers? Yes
No
14.
Do you rent or lease your vehicles to others? Yes No
If yes, attach a copy of rental or lease agreement form used.
15.
Are bodies of all trucks and trailers completely closed and equipped with snap locks? Yes No
16.
Are trucks equipped with alarms? Yes No Other
17. Number of men on trucks?
Are loaded trucks ever left unattended? Yes No
CARGO INFORMATION
Select Type of Cargo Coverage Desired:
Named Perils
Broad Form (not available for all types of cargo)
Limit of Insurance
Deductible
Describe Cargo Hauled % of Hauling Maximum Value Average Value
SEE
SCHEDULE OF
AUTOS/VEHICLES
$ 500
$ 1,000
$ 2,500
Other
*100% co-insurance clause applies. If applicant hauls double wide mobile homes, cargo limit 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.
18. Additional Coverage Options (additional premium may apply):
Additional Insured Endorsement (Lessee) Loading and Unloading Coverage
Tow Truck Amendatory Endorsement
Earned Freight Coverage Refrigeration Breakdown Coverage Hired Car Cargo Coverage Exclude Theft Coverage
DRIVER INFORMATION – If additional space is needed, attach separate listing.
Driver's Licenses
Experience
Driver's Name Date of Birth
State Number
Class/Type
(i.e. CDL)
Years
Licensed (in
class/type)
Type of Unit
(bus, van,
etc.)
No. of
Years
1.
2.
3.
4.
5.
M-5561 MD (12/2010) Cargo Application Page 1 of 3
Accidents and Minor Moving Traffic
Viola
tions in Past 5 Years
Major Convictions
(DWI/DUI, hit & run, manslaughter, reckless,
driving while suspended/revoked, speed contest,
other felony)
No. Years
Previ
ous
Commercial
Driving
Experience
Date of Hire
No. of
Accidents
Date(s)
No. of
Violations
Date(s) Describe Conviction Date(s)
Employee (E)
Ind. Cont. (IC)
Owner/Op. (O/O)
Franchisee (F)
1.
2.
3.
4.
5.
PLEASE ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE.
19. Mi
nimum Years Driving Experience Required
Are vehicles owner-driven only? Yes No
20.
Are drivers ever allowed to take vehicles home at night? Yes No
21.
Do you order MVRs on all drivers prior to hiring? Yes No
Driver's Maximum Driving Hours daily, weekly
22.
Do you agree to report all newly hired operators? Yes No
SCHEDULE OF AUTOS/VEHICLES (Describe all vehicles for which application is made for insurance)
Veh.
No.
Model
Year
Vehicle Make
& Model
Body Type
(truck,
tractor,
trailer, etc.)
Full Vehicle Identification
Number
Gross
Vehicle
Weight
(GVW)
Total
# of
rear
axles
Principal Garaging
Location
(city & state)
Radius
of
Opera-
tion
Cargo Limit
(if coverage is to
attach to vehicle)
1
2
3
4
5
6
7
8
9
10
23.
Insured Desires Cargo Coverage to Attach to: Power Unit Trailer/Semi-Trailer
24.
Will lessor be added as additional insured? Yes
No If yes, give name and address of lessor for each vehicle
25. Number of Vehicles Owned: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
26. Number of Vehicles Leased: Pick-Ups Trucks Tractors Semi-Trailers Trailers Pup Trailers
LOSS EXPERIENCE – Provide prior insurance carriers information for past full three years.
Policy Term Total
Amount Claims Paid & Reserves
From To
Ins
urance Company Name
No. of Motor
Powered
Vehicles
No. of
Accidents
Total Premium
BI/PD Comp/Coll Cargo
/ / / /
/ / / /
/ / / /
27.
Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage
sought in this application? Yes No If yes, provide complete details
28.
Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No If yes, date and why
FILING INFORMATION
29.
Is an FHWA filing required? Yes No
C
Common Contract Broker
If yes, MC number
Do you require FHWA cargo filing? Yes No
30. If you hold a broker’s license, identify name filed with FHWA, FHWA docket no. and receipts from brokerage operations
31. If you are an interstate regulated carrier, identify your registration or base state
32.
Is an intrastate cargo filing needed? Yes No
If yes, show state and permit number
List states for which insured requires CARGO FILINGS (check name on permits)
33. Show exact name and address in which permits are issued
M-5561 MD (12/2010) Cargo
Application Page 2 of 3
34.
Is our policy to cover all vehicles owned, operated or under lease to applicant? Yes No If no, explain
35.
Is oversize, overweight cargo hauled? Yes No
36.
Does your authority allow for transportation of hazardous commodities? Yes No
37.
Do you allow others to haul hazardous commodities under your authority? Yes No
38.
Have you ever changed your operating name? Yes No Do you operate under any other name? Yes No
39.
Do you operate as a subsidiary of another company? Yes No
40.
Do you lease your authority? Yes No Do you appoint agents or hire independent contractors to operate on your behalf? Yes No
41.
Have you purchased, sold or applied for authority over the past 3 years? Yes No
42.
Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.)? Yes No
43.
Is evidence/certificate(s) of coverage required? Yes No
44. Please explain any "yes" answer to Questions 38 through 43
45.
Do you have agreements with other carriers for the interchange of vehicles or transportation of passengers? Yes No
If yes, attach a copy of current agreements and complete the following:
(a)
(b)
(c)
With whom has such agreement(s) been made?
Under whose permit does each of the parties to the agreement(s) operate?
Is there a Hold Harmless in the agreement(s)? Yes No
46.
Do you barter, hire or lease any vehicles? Yes No
If yes, explain
MUST BE SIGNED BY THE APPLICANT PERSONALLY
No coverage is bound until the Company advises the Applicant or its representative that a policy will be issued and then only as of the
policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's Representative named below is
acting as Applicant's agent and not on behalf of the Company. The Applicant's Representative has no authority to bind coverage, may
not accept any funds for the Company, and may not modify or interpret the terms of the policy.
The Applicant agrees that the foregoing statements and answers are true and correct. The Applicant requests the Company to rely on its
statements and answers in issuing any policy or subsequent renewal. The Applicant agrees that if its statements and answers are materially false,
the Company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be
attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the Company in accordance with the terms of that
endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to
insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the
Applicant or any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business
background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional
information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has
personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
Will premium be financed? Yes No If yes, with whom
ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF
A LOSS OR BENEFIT OR WHO
KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION
FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Witness Applic
ant's Signature Date
TO BE COMPLETED BY APPLICANT'S REPRESENTATIVE
Is this direct business to your office?
If not, explain
Is this new business to your office? If not, how long have you had the account?
How long have you known applicant?
REQUEST TO COMPANY GENERAL AGENT:
Please quote Please bind at earliest possible date and issue policy
Please issue policy effective Coverage was bound by
(Time and Date Bound by General Agent) (Nam
e of Person in Company General Agency's Office Binding Coverage)
Applicant's Representative's Name and Address Phone
No.
M-5561 MD (12/2010) Cargo A
pplication Page 3 of 3
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Form 5.: Cargo Application COLUMBIA INSURANCE COMPANY Business (Risk Placement Services, Inc.)

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Completed 23 November 2020

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