13727 Noel Rd, Galleria North Tower II, Ste 1000, Dallas, TX 75240
Broker:
Excess Transportation Supplemental Application
UL Coverages:
Effective Date:
Limits Requested:
Name Insured: ANI's (if app.):
Mailing Address: Physical Address:
Zip Code:State:City: Website:
Submission Includes:
Acord Applications Trucking Supplemental (required) Exposure History (Units/Miles/Rev.)
Vehicle Schedule 5 years currently valued Loss Runs Loss Summary Underlying Quotes
Description of Operations/Commodities:
Projected Exposures:
Revenue: $ Mileage: Unit Count:
Subhauler COH: $
HNOA: $
TBL Revenue: $
0-50
Radius of Operations (%):
51-200 201-500 >500
Private Passenger:
Unit Count:
Extra-Heavy Trucks:
Light Trucks: Medium Trucks: Heavy Trucks:
Heavy Tractors: Extra-Heavy Tractors: Total:
Expiring Info. (if applicable)
Limit: Premium: $ Exp. Unit#: Tgt Pricing: $
DOT#(s):
FMCSA/SAFER:
DOT Rating:
Current: $
Auto Liability Loss History:
Year: # Claims: Total Incurred:
1st Year: $
2nd Year: $
3rd Year: $
4th Year: $
# of
Units:
$
Total Incurred:Date:
Liability Losses >$100,000
$
$
$
$
Additional Notes:
(including special endorsements, safety/
technology information, SAFER corrective
measures, etc.)
NOTE: Once this form is completed, save the file to your computer.
Yes
Auditable:
No Other
N/A
N/A N/A
