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MOTOR CARRIER APPLICATION (Risk Placement Services, Inc.)

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CA-APP-25 (6-15) Page 1 of 5
National Casualty Company
Scottsdale Surplus Lines Insurance Company
Home Office: Scottsdale, Arizona
Adm. Office: 8877 Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
MOTOR CARRIER APPLICATION
Name of Applicant:
D/B/A:
Mailing Address:
Garaging Address:
(if different than mailing)
Phone Number:
DOT No.:
Loss Control contact name and telephone number:
E-mail Address:
Insured Website:
Agent Name:
Producer:
Phone No.*:
Address:
Agent No.:
*Required on Fleets to assist Loss Control
PL
EASE ANSWER ALL QUESTIONS
PROPOSED EFFECTIVE DATE: From: To: 12:01 A.M., Standard Time, at the address of the applicant.
DESCRIPTION OF OPERATIONS
1. Applicant is: Individual Partnership Corporation LLC Other:
2. How long has this operation been in business? Years trucking management experience:
3. Any other business currently owned or operated by the insured currently or in the past five
years? .........................................................................................................................................................
Yes No
If yes, provide name and description of operations:
4. Has there been any change in operations, ownership, management, or name during the last five
years? .........................................................................................................................................................
Yes No
If yes, provide details:
5. Radius of operations:
0-100 mi. % 101-300 mi. % 301-500 mi. % Over 500 mi. %
If more than 500 miles, approximately what percent of your miles will you travel to or through these four regional
zones:
ZONE 1: CA, NV,
OR, WA
ZONE 2: AZ, CO, IA, ID, IL,
IN, KS, MI, MN, MO, MT, ND,
NE, NM, OH, SD, UT, WI, WY
ZONE 3: AL, AR, FL, GA,
KY, LA, MS, NC, OK, PA,
SC, TN, TX, VA, WV
ZONE 4: CT, DE, MA,
MD, ME, NH, NJ,
NY, RI, VT
%
%
%
%
6. Are filings required?.................................................................................................................................. Yes No
If yes, provide list:
7. Are any vehicles owned, operated or leased that are not included in the vehicle schedule? .......... Yes No
If yes, provide details:
8. Do you have motor carrier brokerage authority? ................................................................................... Yes No
If yes, in what name? and under what DOT number?
What name appears on the bill of lading as the carrier?
Brokerage revenue for the last twelve (12) months:
Estimated brokerage revenue next twelve (12) months:
CA-APP-25 (6-15) Page 2 of 5
9. Do you have a signed trailer interchange agreement? (If yes, provide copy of agreement)................. Yes No
10. Are any vehicles or equipment loaned, rented, or leased to others? (If yes, provide copy of
agreement) ..................................................................................................................................................
Yes No
Are these units scheduled on this policy? ................................................................................................... Yes No
11. Do you use owner/operators? .................................................................................................................. Yes No
If yes, are they scheduled on the policy? .................................................................................................... Yes No
12. Do you use sub-haulers? (If yes, provide copy of sub-haul agreement) .................................................. Yes No
13. Do you hire, rent, or borrow any vehicles from others? ....................................................................... Yes No
If yes, will they be scheduled on the policy? ............................................................................................... Yes No
What is the average term of the lease?
Provide your annual cost to lease, hire, rent, or borrow vehicles:
With drivers $ Without drivers $
14. Do you use double trailers? ................... Yes No Do you use triple trailers? ......................... Yes No
15. Are passengers allowed? ......................................................................................................................... Yes No
If yes, what controls are in place?
If yes, what is the frequency of passengers?
COMMODITIES HAULED
Commodity % of Loads Average Value Maximum Value
16. Are hazardous materials or hazardous waste hauled? (If yes, provide details in table above) ............ Yes No
If yes, do you require a $1 million ($1.2 million in CA) or $5 million filing? ............................. $1 million $5 million
DRIVER INFORMATION
17. Criteria for hiring drivers: Minimum age: Minimum years of experience:
Describe your MVR standards:
Do you use PSP (Pre-Employment Screening Program) in your hiring process? ...................................... Yes No
* Note: If operating in this name less than two years, Driver Employment Histories are required for all drivers (Form
ADM 1003).
18. The driver list provided includes drivers of all vehicles requested to be covered under the pol-
icy including employees, leased employees, mechanics, family members, as well as any other
person allowed to drive an insured vehicle. I agree to notify my agent of any additional drivers
before they are allowed to drive an insured vehicle. .............................................................................
Yes No
19. List below all drivers employed as of the proposed effective date:
Driver’s Name
Date
of
Birth
Driver’s
License
No.
State
No. of
Years
Driving
Similar
Vehicle
Date of
Hire
List Past Three
Years of Accidents &
Traffic Violations
CA-APP-25 (6-15) Page 3 of 5
INSURANCE AND LOSS HISTORY
20. Have you had any insurance canceled, declined or non-renewed or filed bankruptcy in the last
three years? (Not applicable in Missouri) ...................................................................................................
Yes No
If yes, explain:
21. Provide loss history for prior five years:
Policy
Period
Prior
Carrier
Policy
No.
No. of
Units
Insured
No. Of
Losses
Liability
Losses
Paid/Open
Phys. Dam.
Losses
Paid/Open
Cargo
Losses
Paid/Open
OPERATION HISTORY
22. Provide prior three years, current and projected business history:
Year Gross Receipts Mileage Number of Power Units
Current Year
Projected for Coming Year
SCHEDULE OF COVERED AUTOS
23. Provide autos to be scheduled on policy:
No. Year
Make/
Model
VIN No. (17 Digits) GVW/GCW Stated Value Radius
Owner’s
Name
Trailer
Type*
$
$
$
$
*Trailer Types: Car Carrier-CC, Container-CO, Dump Belly-DB, Dump End-DE, Flat Bed-FB, Hopper/Grain-HP, Livestock-LV, Log-LG
Mobile/Modular Homes-MH, Tank, Dry Bulk/Pneumatic-TD, Tank, Liquid-TL, Van, Dry-VD, Van, Reefer-VR
LIENHOLDER INFORMATION
No. Name Address City State Zip Code
24. Does equipment have safety features such as Collision Avoidance Systems, Lane Departure
Warning, GPS, Advance Stability Equipment, Brake Monitoring, etc.? ...............................................
Yes No
If yes, describe:
LIMIT AND COVERAGE INFORMATION
25. Liability: Combined Single Limits $
26. Non-Trucking: $ Leased to:
27. Hired Auto: Cost of Hire: $ (Hired auto coverage is subject to audit)
CA-APP-25 (6-15) Page 4 of 5
28. Hired Auto Physical Damage Limit: $ Deductible: $
29. Non-owned Auto: Number of Employees: (Non-owned auto coverage is subject to audit)
30. Uninsured Motorist: Rejected Limits Accepted: $
31. Underinsured Motorist: Rejected Limits Accepted: $
(Complete appropriate state UM/UIM Selection/Rejection Form)
32. Mandatory no-fault state: (Complete appropriate Personal Injury Protection Selection/Rejection Form.)
PIP basic limits accepted? ........................................................................................................................... Yes No
33. Optional no-fault state: PIP rejected?....................................................................................................... Yes No
34. Medical Payments: Rejected Limits Accepted: $
35. Trailer Interchange: Limit: $ Deductible: $ No. of Trailer Days:
36. Deductibles: Comp. $ SCOL $ Coll. $
37. Cargo: Limit: $ Deductible: $
Check all boxes that apply if coverage desired while hauling these commodities:
Copper Aluminum Autos Mobile Homes Reefer Breakdown Spoilage Owned Goods
38. Policy Type:
Scheduled Unit Reporting Form basis: Per Power Unit Receipts Mileage
This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein
shall be the basis of the contract should a policy be issued.
California Notice And Disclosure: Please note a policy fee of $150 applies to NEW business policies only. This policy
fee is fully earned at policy inception.
FRAUD WARNINGS
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT, or WA)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an in-
surance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance pol-
icy for commercial or personal insurance which such person knows to contain materially false information concerning any
fact material thereto; 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
CA-APP-25 (6-15) Page 5 of 5
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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.
NOTICE TO OKLAHOMA APPLICANTS: 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 infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable in Florida Agents Only)
IMPORTANT NOTICE
As part of the underwriting procedure, a routine inquiry may be made which will provide applicable information
concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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MOTOR CARRIER APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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