Fillable MICHIGAN TRUCK FLEET APPLICATION (Special Risks)

Fill Online, Printable, Fillable, Blank MICHIGAN TRUCK FLEET APPLICATION (Special Risks) Form

Use Fill to complete blank online SPECIAL RISKS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MICHIGAN TRUCK FLEET APPLICATION (Special Risks)

On average this form takes 100 minutes to complete

The MICHIGAN TRUCK FLEET APPLICATION (Special Risks) form is 7 pages long and contains:

  • 3 signatures
  • 106 check-boxes
  • 337 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Special Risks forms online.

BROWSE SPECIAL RISKS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 1 of 6
MICHIGAN
TRUCK FLEET APPLICATION
11 or More Power Units
Entire Application Must Be Completed and Signed
Submission Number:
Proposed Effective Dates: FROM: TO:
GENERAL INFORMATION
Individual Corporation Partnership LLC Other ________________________________
Name
Mailing Address
City State ZIP Code Business Phone
E-Mail Address
Garaging Address
(if different)
City State ZIP Code
Tax ID: Federal ID # or SS # U.S. DOT # MC # Yrs. Applicant has been Operating Under
Business Name
Safety Contact Person Name Contact’s Phone
Safety E-Mail Address
OWNER / PRINCIPAL
Name (First, Middle, Last) Yrs. Experience in Trucking
SS # of Owner Home Address Apt. #
City State ZIP Code Business Phone
DESCRIPTION OF OPERATIONS
Type of Operation: For Hire Not For Hire Non-Trucking Private
Do you engage in operations other than trucking? Yes No
If yes, explain: ____________________________________________________________________________________
Has there been any change in the nature of operations, ownership, management or the name of the operation during the
last five years? Yes No
If yes, provide details: ______________________________________________________________________________
Range of Transport
Interstate Intrastate
Percent of Loads: 0 - 100 Miles ______ 101 - 300 Miles ______ 301 Miles + _______
Longest Trip One Way: _________ Miles
OPERATIONS LESS THAN 300 MILE RADIUS - List City Destinations Below
1 2 3 4
OPERATIONS BEYOND 300 MILE RADIUS: Identify Metropolitan Areas Traveled Through Or Into
Atlanta Cleveland Jacksonville Milwaukee Orlando Salt Lake City
Balt-Washington Dallas/Ft. Worth Kansas City Mpls./St. Paul Philadelphia San Diego
Boston Denver Little Rock Nashville Phoenix San Francisco
Buffalo Detroit Los Angeles New Orleans Pittsburgh Seattle
Charlotte Hartford Louisville New York City Portland Tampa
Chicago Houston Memphis Oklahoma City Richmond Tulsa
Cincinnati Indianapolis Miami Omaha St. Louis
Cities other than above or regular routes _____________________________________________________________
Percent of regular routes _________________
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 2 of 6
Commodities Hauled (Check all that apply
.
)
Refuse/Waste/Garbage
Hazardous Materials requiring $1,000,000 liability limits or less
Hazardous Materials requiring liability limits in excess of $1,000,000 (if checked, attach explanation)
COMMODITIES TRANSPORTED
Commodity Percent
of Loads
Maximum Value Commodity Percent
of Loads
Maximum Value
List major shippers you haul for: ______________________________________________________________________
________________________________________________________________________________________________
YES NO
1. Are filings required? If yes, complete Filing Information form.
2. Do you act as a freight-broker or freight-forwarder or arrange loads for others?
If yes, attach copy of agreement and provide:
Brokerage Name: ____________________________________________ MC #: ________________
Annual Brokerage Revenue: $ __________________
3. Is all equipment operated under the app
licant’s authority scheduled on the application?
a. If no, attach explanation.
b. Indicate % of loads brokered to you by others: __________
4. Is all owned equipment scheduled on this application? If no, attach explanation.



5. a. Do you lease your power units to others?
b. Do you lease your trailers to others?
c.
If yes, who must provide primary liability coverage? You Lessee
6. Do other motor carriers or owner-operators haul for you?
If y
es, complete questions below
, complete Hired Autos Application Supplement and attach copy
of lease agreement. If no, skip to question #7.
A.
Name on the Bill of Lading: Yours
Others
B.
On what basis are they leased?
Permanent
Basis
Temporary/Trip
Basis
C. Provide annual cost of hire or # of trips
____________ _____________
D. Are vehicles leased with driver?
Yes No Yes No
E. Are leased vehicles included in this application for insurance?
(1) If yes, do you require leased vehicle owners to purchase
non-trucking liability coverage?
(2) If
no:
a.
Is there a written lease agreement stating the lessor
will provide primary auto liability coverage while
leased to you?
b.
Limit of Liability required
c. Do you secure evidence the lessor has primary auto
liability coverage?
d.
Does the lease state that the lessor agrees to provide
you with 30 days advance notice if their insurance
coverage is being cancelled or reduced?
Yes No
Yes
No
Yes No
$ ___________
Yes No
Yes No
Yes No
Yes No
Yes No
$ ___________
Yes No
Yes No
7. Do you pull doubles? Yes No Triples? Yes No
8. Do you haul intermodal containers?
9. Is any portion of your operation seasonal? If yes, explain. __________________________________
10. Do you use any team, hot seat, slip seating or relay driver operations?
11. Do you allow passengers other than company employees? If yes, attach copy of passenger program
or explain program (frequency, requirements), etc.
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 3 of 6
Y
es No
12. Do you operate more than one terminal? If yes, provide the following:
Location(s) # Units Max. Equip. Value Address, City, State
13. Do you sign contracts with shippers that give the shipper the right to determine cargo salvage values or
declare cargo a total loss regardless of actual damage in the event of a loss? If yes, attach a copy of
the contract.
14. Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor
vehicle insurance law in the state where it is licensed or principally garaged? If yes, and need Liability
Coverage, complete Mobile Equipment Supplement.
15. Do you require use of escort vehicles?
If yes and escort vehicles are not included in this application for insurance, provide the name of the
insurance carrier, policy number and auto liability and general liability limits.
If yes and escort vehicles are included
in this application, drivers of escort vehicles should be listed in
the Driver Information section.






16. Do you haul over size, over weight loads? If yes, explain below or attach explanation.
_________________________________________________________________________________
17.
Do you haul to/from well drilling sites? If yes:
a. List commodities hauled: _________________________________________________________
b.
Percent of loads these commodities represent for your business: __________________________
18. Do you haul to/from mines?
a. List commodities hauled: _________________________________________________________
b. Percent of loads these commodities represent for your business: __________________________
SCHEDULE OF EQUIPMENT OPERATED
Provide a schedule of equipment to include Make,
Y
ear, Type*, VIN Number, GVW, Stated Limit, Radius of
Operation, Ownership Status and Additional Interest information. Refer to Legends below.
The Stated Limit of each auto must be equal to or greater than the outstanding financial obligation for that auto in order
for the Financed Value Coverage to apply.
Type Owned Leased w/o
Drivers
Owner
Operators
Local Inter. Long
Haul
TOTAL
UNITS
Light Trucks
Medium Trucks
Heavy Trucks
Tractors
Semi-Trailers
To ensure Electronics (as defined by the policy), along with tarps, chains or binders are covered, include the value in
each auto’s stated value.
Ownership Legend
1 – Owned 3 – Employee Owned 4 – Leased w/ Driver Incl. Non-Trucking
2 – Leased Without Driver 5 – Leased w/ Driver Excl. Non-Trucking
*
V
ehicle Type Legend
CCT - Car Carrier Trailer
CON - Container (Intermodal)
CUS - Curtain Side
DOL - Dolly, Con Gear
DRP - Drop Deck, Gooseneck
DPS - Dump Side
DPB - Dump Trailer (Bottom)
DPE - Dump Trailer (End)
FLT - Flat Bed
HOP - Hopper/Grain
LWF - Live/Walking/Floor
LIV - Livestock
LOG - Log
LOW - Lowboy
MEQ - Mobile Equipment
PUL - Pull Trailer
PUP - Pup Trailer
SEM - Semi Trailer
TAN - Tandem
TAT - Tank Trailer
TAA - Tanker Asphalt/Hot Oil
TAC - Tanker Chemical/Acid
TAG - Tanker Gasoline/Fuel
TAL - Tanker LPG
TAP - Tanker Pneumatic/Dry Bulk
TAO - Tanker-Other
NOC - Trailers Not Otherwise Classified
TRC - Tractors
TRK -Trucks
VAD - Van Trailer (Dry)
REF - Van Trailer (Temp Control)
Additional Interests
AI – Additional Insured AL – Lessor; Additional Insured and Loss Payee LP – Loss Payee
LI – Leased with Driver Including Non-Trucking LX – Leased with Driver Excluding Non-Trucking
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 4 of 6
UNITS REVENUE AND MILEAGE - Actual and Estimated
Period Units Revenue Mileage
Projected
Current
1
s
t
Prior
2
n
d
Prior
3
r
Prior
4
th
Prior
SUMMARY OF EQUIPMENT VALUES
Total Value No. of Units Average Value
Fleet
Tractor
Trailer
INSURANCE HISTORY & LOSS EXPERIENCE - Provide the following insurance and loss information for the past
3 years.
1. Has an insurance company cancelled or non-renewed your policy in the last 3 years?
Yes
No If yes, explain: ____________________________________________________________________
2. Prior years insurance under business name with: Primary Auto Liability: _______
Non-Trucking Auto Liability: _______
3. Indicate other company name(s) you have operated under in the last 3 years:
Company Names: ______________________________________________________________________________
Insurance Provider(s): ___________________________________________________________________________
EXPERIENCE INFORMATION - Furnish currently valued (must be value dated within the last 3 months) Insurance
Company produced detailed loss and experience auto liability, physical damage and cargo loss runs for current year plus
at least two (2) full policy years. Describe any claim with payment or reserves over $25,000.
Coverage Type*: P=Phys. Dmg. C=Cargo L=Prim. Liab. N=Non-Trk. Liab. GL=Genl Liab. IM=Inland Marine
Prior Carrier Effective Dates Prior Carrier Name Policy Number
Coverage
Type*
# Units
Insured
#
Losses
to
to
to
LOSS HISTORY – Past 3 Years (including Drivers no longer employed)
Driver Name
(Last, First, Middle)
Date of
Accident
Amount of Accident Description
DRIVER INFORMATION
Provide a list of drivers that includes the Driver’s Name, DOB, License Number & State, Social Security Number,
Date of Hire, and Years of Driving Experience.
1.
Truck Fleet - No. of drivers: Regularly Employed Part Time Owner/Operator
Leased Casual TOTAL
How are drivers paid? Hourly Trip Mileage Other
2.
Drivers Hired or Leased Last Year Company Drivers Leased Owners/Operators
a. Number replaced
b. Number increased
c
. Age Min. Max. Min. Max.
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 5 of 6
DRIVER HIRING, TRAINING AND SAFETY
1. Which of the following is part of your driver screening/hiring process:
Employment background check
Criminal background check
Motor vehicle record (MVR) review
Pre-employment drug test
Road test
Pre-employment Screening Program (PSP) Report from FMCSA
2. Which of the following is part of your driver performance management process:
Annual review of driver’s driving record (MVR)
Periodic review of driver and vehicle out-of service
violations (SMS/CSA Reports)
Periodic review of accidents/incidents
Review of electronic vehicle driver performance data
(telematics)
Incentives for violation-free and accident-free driving
Formal corrective action procedures
Driver safety training
3. Do you adhere to a written vehicle inspection and maintenance program? Yes No
If yes, describe or attach program. ________________________________________________________________
4. How often do you replace your equipment? __________________________________________________________
5. Do you have any type of theft avoidance policies? Yes
No
If yes, describe or attach policy. ___________________________________________________________________
6. Do you use any of the anti-theft devices to track equipment? Yes
No
If yes, describe: ________________________________________________________________________________
7. Do you have a Safety Director? Yes No
If yes: Full Time Part Time # Years with Company: _______________
COVERAGES
AUTO LIABILITY Limits: $ CSL
LIABILITY FOR NON-TRUCKING USE Limits: $ CSL
Leased to:
EMPLOYERS NONOWNERSHIP LIABILITY Number of Employees
HIRED AUTO LIABILITY Cost of Hire
REPORTING BASIS: Revenue Mileage Units
DEDUCTIBLE REIMBURSEMENT Complete and Attach Supplement
TRAILER INTERCHANGE Provide a Copy of Agreement
# of Power Units Under Agreement: Maximum Trailer Value:
# Trailer Days per Power Unit:
PHYSICAL DAMAGE DEDUCTIBLES
Comprehensive ______________ OR Specified Causes of Loss ______________
Collision ______________
HIRED AUTO PHYSICAL DAMAGE Complete and Attach Supplement
CARGO Limit ___________________ Deductible _______________
OPTIONAL CARGO COVERAGES: (Check all that apply)
Temperature Control Electronics Hired Auto Cargo
Aluminum, Copper Hard Liquor Cost of Hire: _____________
Additional Earned Freight Increase Limit to $5,000 Pharmaceuticals
COMBINED DEDUCTIBLE
Coverage included unless declined.
Decline Combined Deductible
RENTAL REIMBURSEMENT
Selected Units OR All Units
Amount Per Day: ___________ Days of Coverage: 30 120
UNINSURED/UNDERINSURED MOTORIST OPTIONS
Uninsured Motorist (Includes Underinsured Motorist) Limits:
NO-FAULT PROPERTY DAMAGE LIABILITY COVERAGE
This coverage is subject to a limit of $1,000 per claim. The coverage will either pay for the damage payment legally
required or will reimburse you for such payment made resulting from a small claims court judgment.
I want no-fault property damage liability coverage included in my policy.
N-2379 MI (9/14) © 2014 The Travelers Indemnity Company. All rights reserved. Page 6 of 6
For information about how Northland compensates its agents, brokers and program managers, please visit this website:
http://www.northlandins.com/Producer_Compensation_Disclosure.asp
If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance
Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102.
This application, including any material submitted in conjunction with the application or any renewal, does not amend the
provisions or coverages of any insurance policy or bond issued by Northland. It is not a representation that coverage
does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and
circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability
of coverage referenced in this document can depend on underwriting qualifications and state regulations.
SIGNATURES
I authorize Northland Insurance Companies to obtain a copy of any Motor Vehicle Report for rating/underwriting the
insurance for which I have applied. I also understand that a routine inquiry may be made providing information
concerning my character, general reputation, personal characteristics and mode of living. Upon written request,
information as to the nature and scope of the report will be provided to me.
Disclosure: In connection with this application for commercial automobile insurance, we may review a credit report or
obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third
party in connection with the development of the insurance score. The credit report/credit-based insurance score will not
be used for any purpose other than the underwriting of the commercial automobile insurance policy for which you have
applied.
I authorize Northland Insurance Companies to obtain a credit report, including but not limited to a credit-based insurance
score based on personal information provided. This authorization is valid for future reports obtained for renewal policies
with Northland Insurance Companies.
I hereby certify that the foregoing statements and answers are a just, full and true exposition of all the facts and
circumstances with regard to the risk to be insured, insofar as same are known to me, and the same are hereby made as
the basis and condition of the insurance. By signing below, I affirm full knowledge of and adherence to current D.O.T.
Safety Regulations, and hereby apply for insurance with respect to the coverages stated herein.
APPLICANT’S SIGNATURE DATE APPLICANT’S TITLE
APPLICANT’S PRINTED NAME
PRODUCER’S SIGNATURE PHONE # FAX #
click to sign
signature
click to edit
click to sign
signature
click to edit
Name
N-3521 (6/10)
Address
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
PERSONAL INJURY PROTECTION
MICHIGAN
PERSONAL INJURY PROTECTION (NO-FAULT) COVERAGE
Michigan law requires that every motor vehicle liability policy, except a policy for a motorcycle, shall automatically
include Personal Injury Protection (No-Fault) coverage and Property Protection coverage. Your motor vehicle liability
policy will include Personal Injury Protection (No-Fault) coverage and Property Protection coverage.
COORDINATION OF BENEFITS
Your Personal Injury Protection benefits premiums may be reduced for autos owned by an individual named insured if
there is applicable health and accident coverage available to the named insured, the named insured's spouse and any
other relatives of the named insured who reside with the named insured.
You may elect to make such other available health and accident coverage primary and your Personal Injury Protection
coverage provided under your motor vehicle liability secondary by making an election as indicated below:
I have other health and accident coverage which covers any
allowable medical expenses
available under Personal
Injury Protection coverage and I elect to make my Personal Injury Protection coverage secondary over the other
available health and accident
coverage with respect to such
allowable medical expenses
.
I have other health and accident coverage which covers any
work loss benefits
available under Personal Injury
Protection coverage and I elect to make Personal Injury Protection coverage secondary over the other available
health and accident coverage with respect to
such
work loss benefits
.
I have other health and accident coverage which covers any
allowable medical expenses
and
work
loss
benefits
available under Personal Injury Protection coverage and I elect to make Personal Injury Protection coverage
secondary over the other available health and
accident coverage with respect to such
allowable medical expenses
and
work loss
benefits
.
I
understand
that
my
coverage
election
shall
apply
on
the
policy
or
policies
in
effect
at
the
time
this
form
is
executed
and
all future renewal policies until I notify the Company IN WRITING of any changes.
My
signature
below,
and/or
payment
of
any
premiums
evidences
my
actual
knowledge
and
understanding
of
the
availability of these benefits and limits as well as the benefits and limits I have selected, rejected or accepted by default.
Signature of Named Insured
Date
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MICHIGAN TRUCK FLEET APPLICATION (Special Risks)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document