Fillable LIVESTOCK TRANSPORTATION APPLICATION (Standard Lines Services)

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LIVESTOCK TRANSPORTATION APPLICATION (Standard Lines Services)

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THE HARTFORD - LIVESTOCK DEPARTMENT
(800)-295-1815
www.hartfordlivestock.com
LIVESTOCK TRANSPORTATION APPLICATION
Producer’s Name
Applicant’s Name
Agency Code
Mail Address
Mail Address
City, ST Zip
,
City, ST Zip
,
Phone
( ) -
Phone
( ) -
Fax
( ) -
Fax
( ) -
E-mail Address
E-Mail Address
Individual
Partnership
Corporation
Joint Venture
Limited Liability Corporation
Other
Year Business Started
Proposed Effective Date:
Inspection Contact
Phone
( )
Type of Coverage Requested: Optional Coverage Extension(s) Requested:
Livestock Transit Coverage Form Livestock Transit Coverage Form Carcass Removal Substitution of Vehicles
(Limited-Named Peril LS 00 21) (Broad LS 00 20) (LS 20 01) (LS 20 06)
Additionally Covered Property
in Transit Coverage Form
Additionally Covered Property
in Transit Coverage Form
Your Property On Your Vehicles
(LS 20 11)
(Limited-Named Peril LS 00 27) (Broad LS 00 26)
Other
Optional Endorsement(s) Requested:
Payment Schedule: Deposit Attached $ Rate Quoted:
Livestock Transit Liability Limit: (any one vehicle) Livestock Transit Liability Limit: (any one animal)
Additionally Covered Property Liability Limit: List All Commodities Transported:
1. Are state filings required: Yes No If Yes, list states:
2. Specify how name should appear on filing(s):
3. If ICC filing(s) are required, please include the following: US DOT Filing Number: MC Filing Number:
4. If available, attach copy of driver(s) Motor Vehicle Record.
5. Name of current cargo carrier: Current cargo policy expiration date:
6. List percentages of livestock to be hauled:
Horses Mules Sow/ Boars Butcher Hogs
Stocker/Feeder Cattle Fat Cattle Dairy Cattle Sheep/Goats
Pre-weaned Pigs Breeding Stock (Specify Type)____________________________
_
7. Average hauling distance: miles. Maximum hauling distance: miles. Estimated loaded miles per year: __________
_
8. Does applicant transport any special valued animals? Yes No If Yes, explain:
9. Indicate if applicant transports for any of the following:
Packer Order Buyer(s) Dealer(s) Farmer(s)
a. Does any entity selected retain any portion of loss before pursuing a claim against the applicant? Yes No
If Yes, explain:
10. Condition of equipment:
Excellent Good Fair Poor Other:
11. Does applicant own, operate or have financial interest in any other similar operation? Yes No If Yes, explain:
12. Loss Payee(s):
(Name and Address)
13. Has applicant ever been canceled or nonrenewed by an insurance company? Yes No (Not applicable in MO)
If Yes, explain:
14. LOSS HISTORY. Please list all losses sustained in the last five years:
Date Of Loss Cause Of Loss Amount Of Loss
Page 1 of 2 ©, Hartford Fire Insurance Company, 2004 LS 16 13 03 04
87-
List the vehicle make, model and identification number on all insured tractors and trailers.
YEAR MAKE MODEL SERIAL NUMBER
(Select Only One Per Vehicle)
1
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
2
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
3
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
4
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
5
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
6
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
7
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
8
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
9
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
10
Tractor Multi Deck Trailer
Truck Single Deck Trailer
Pick-up Gooseneck Trailer
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states,
consult your agent or broker for your state’s requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A
CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR
INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED
INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN
REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES
REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON
HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON
TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.
(Not applicable in CO, HI, NE, OH, OK, OR, or, VT; in DC, LA, ME, TN, and VA, insurance benefits may also be denied. See below for additional Fraud Warnings)
APPLICANTS SIGNATURE DATE PRODUCERS SIGNATURE DATE
Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides
false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or
attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicable in Oklahoma
Warning: any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Applicable in Nebraska, Oregon and Vermont
Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a crime.
Page 2 of 2 ©, Hartford Fire Insurance Company, 2004 LS 16 13 03 04
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LIVESTOCK TRANSPORTATION APPLICATION (Standard Lines Services)

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Completed 7 February 2021

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