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MOTOR TRUCK CARGO PROPOSAL FORM MOTOR TRUCK CARGO (Risk Placement Services, Inc.)

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MOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORMMOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORM
For use with Broad Form (15)
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Use space on last page or attach an extra sheet if there is insufficient room for answers
1. Applicant: ___________________________________________________ doing business as:
Company: ________________________________________________ Year established ______
Address:_______________________________________________________________________
______________________________________________ ICC Docket No. MC______________
2. Names, addresses and functions of Associated or Subsidiary Companies to be included:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Are Companies: a) Common Carriers [ ] b) Private Carriers [ ]
c) Contract Carriers [ ] d) Owner of cargo [ ] e) Other [ ] (Please give details at end of form)
If you contract on a released liability basis please attach a copy of a specimen waybill showing how much liability you accept.
Also please give details of your additional valuation rates and the approximate annual level of additional valuation charges you
receive.
4. a) Please give details of any operations carried out other than that of a carrier______________
______________________________________________________________________________
b) Do you subcontract to other parties? ___________ If so on long term (30 day+) leases or other
basis? (give details)______________________________________________________________
c) Are subcontractors responsible and insured for loss or damage to the cargo you subcontract to
them? _____________ If so, do you maintain copies of their current insurance arrangements on
file? __________________________________________________________________________
5. Please give gross receipts in respect of your trucking operations for past 5 years:-
YEAR G.R. Own haul G.R. Subcontracted out Total G.R. all operations
6. The following interests are excluded under the basic policy form, but can normally be covered
at additional premium if requested. Please circle any you wish to be covered, and include details
of such exposures in answer to question 8: Accounts, bills, debts, evidence of debt, letters of
credit, passports, documents, railroad or other tickets, notes, money, securities, currency, bullion,
precious stones, jewelry &/or other similar valuable articles, paintings, statuary and other works
of art, manuscripts, mechanical drawings, live animals, tobacco, cigars, cigarettes, non-ferrous
metal in scrap or ingot form, furs, alcohol, liquor, beer, wine, garments (defined as: items of
clothing, including innerwear and outerwear, footwear, shoes, boots, gloves, hats, and the like),
seafood unless canned, and electronics (defined as: all items of consumer and commercial
electrical appliances and instruments including but not limited to radios, stereos, televisions,
computers, computer software, hard drives, chips, modems, monitors, cameras, facsimile
machines, photocopiers, VCRs, hi-fis, CD players and the like. Note: Heavy electrical items,
such as switchgear, turbines, generators and the like are NOT considered to be electronics).
MOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORMMOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORM
For use with Broad Form (15)
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7. Form of cover required: Broad Form [ ] incl Reefer Breakdown ? [ ]
N
amed Peril Form [ ]
8. List by category and percentage of the total loads shipped:
Type of cargo Ave. Value per load Max. Value per load % of total loads
Machinery
Tobacco
Produce
Chilled Food
Frozen Food
Building Materials
9. Do you require cover for cargo in terminals or at other places where vehicles are often left
overnight or at weekends either on vehicles______________? or off vehicles ______________?
If either answer is yes, please give details of any such places which are regularly used:
Address Fenced yard
locked at night?
24 hour
watchman?
Alarmed
Building?
Sprinklered
Building?
Max. value exposed?
10. Limits required: a) $_________________ a.o.vehicle
b) $__________________ a.o.loss (vehicle accumulation)
c) $__________________ a.o.terminal (off vehicles)
If Limit for 10b) is in addition to
10c), specify overall loss limit
needed $________________
Do you ever carry loads valued greater than the cargo insurance limit requested? Yes / No
11. Give details of any steps taken to secure vehicles whenever left
unoccupied._______________
______________________________________________________________________________
______________________________________________________________________________
12. Give details of any I.C.C. or State / Provincial cargo filings required: ____________________
______________________________________________________________________________
MOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORMMOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORM
For use with Broad Form (15)
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Percentage of hauls by distance: 1-250 miles [ ] 251-1000 miles [ ] 1001+ miles [ ]
13. Please give details of the number of vehicles for which cargo cover is required:
Tractor Units
Reefer Trailers 10 yrs old or less
Straight trucks
Reefer Trailers more than 10 yrs old
Reefer trucks
Flat bed trailers
Tank trucks
Tank trailers
Other power units
Other trailers
Total number of power units
Total number of trailers
14. Please give power unit details, year of manufacture, make, model & vehicle identification
numbers if scheduled vehicle policy required:
1
6
2
7
3
8
4
9
5
10
15. Please give driver details:
Total no. of drivers
No. of full time employee drivers
No. under 25 yrs old
No. of drivers on long term (30d+) lease
No. over 60 yrs old
No. of two person driver teams
16. Please give details of checking procedures maintained for employing new
drivers:__________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
17. What are the criteria you use to determine whether to fire existing
drivers?________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
18. Please give details of your cargo loss experience whether insured or not, for the past 5 years,
on an All Risks / Broad Form basis, FROM 1st DOLLAR / NO DEDUCTIBLE
Year Paid Outstanding What happened?
MOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORMMOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORM
For use with Broad Form (15)
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19. Are details of claims within deductibles (‘over, shortage and damage’) maintained? If so,
please give details for the past 3 years:
Year Total amount paid Total amount outstanding
20. Has any insurer within the past 5 years refused to renew, or canceled insurance to the
applicant?:___________ If so please give details:______________________________________
______________________________________________________________________________
21. Please give details of your existing cargo insurance:
Carrier
Existing deductible
Renewal offered?
Existing limit
Existing rate
Expiry date
22. Date from which insurance cover is required: ______________________________________
23. Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance 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.
I/we hereby declare that the statements and particulars given on this form are true to the
best of my/our knowledge and belief and that I/we have not suppressed, withheld or
modified any material facts. I/we agree that should a policy be issued, this form shall be the
basis of the contact, and that any change in the pattern of my/our trade or trade practices
shall be advised to the Underwriters who may at their discretion, vary the terms and
conditions of the contract.
Signed _______________________________________ Dated ________________________
Position ______________________________________
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MOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORMMOTOR TRUCK CARGO PROPOSAL FORM
MOTOR TRUCK CARGO PROPOSAL FORM
For use with Broad Form (15)
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Continued from question : _____________________________________________________
_
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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MOTOR TRUCK CARGO PROPOSAL FORM MOTOR TRUCK CARGO (Risk Placement Services, Inc.)

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Completed 30 July 2020

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