Fillable MOTOR TRUCK CARGO SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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MOTOR TRUCK CARGO SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Page 1 of 8
MOTOR TRUCK CARGO – SUPPLEMENTAL APPLICATION
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
New Venture?
Yes No
Renewal?
Yes No
Policy Number:
Current Effective Date:
Current Expiry Date:
Requested Effective Date:
Requested Expiry Date:
DOT #:
MC #:
Website:
2) Current Carrier Information:
Expiry Date:
Yes No
Please attach copies of the following:
a) Currently valued five-year loss runs, including complete claim details for all losses
b) Applicant’s description of operations, brochure, or marketing materials if a website is not available
c) For new venture MTC operations, please also complete the Kinsale Motor Truck Cargo – New Venture Supplemental
Application
3) Mailing Address:
City: State: Zip Code:
4) Desired Cargo Limits: $50,000 $100,000 $250,000 $500,000 Other:
5) Desired Deductible: $1,000 $2,500 $5,000 Other:
6) Desired Refrigeration Breakdown Limits: $25,000 $50,000 $75,000
$100,000 N/A or None Other:
a. If you are seeking Refrigeration Breakdown, are all reefer units newer than 10 years? Yes No
7) Desired Trailer Interchange Limits: $25,000 $50,000 $75,000 $100,000
N/A or None Other:
a. Number of trailers:
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 8
b. Total number of trailer days (including all trailers):
8) Are you a(n): Corporation Individual Partnership Municipality For Profit
Joint Venture Other:
9) What type of carrier are you? Common Contract Private (owner’s goods and vehicle)
10) Are filings Required? Yes No
11) How long have you been in operation under this business name or any others (please provide any prior entities or
additional entities/DBAs to be covered)?
12) Please complete the following table for your receipts and payroll:
Revenue
Payroll
Estimated Mileage
Projected Year
Last 12 Months
2nd Prior Year
3rd Prior Year
4th Prior Year
13) What is the total number of power units you own or operate?
14) What is your average length of haul? miles
15) Please complete the following radius of operations table:
Local (0 to 50 miles):
%
Short Haul (51 to 300 miles):
%
Medium Haul (301-500 miles):
%
Long Haul (501-1,500 miles):
%
Very Long Haul (1,501+ miles):
%
TOTAL
100%
a. What are your principle states of operation?
b. Do you have any operations in Mexico or Canada? Yes No
16) Do you travel through major metropolitan areas? Yes No
a. If Yes, which?
17) What operations do you engage in? Check all that apply:
Dry Van/Box Flat Bed Intermodal Bulk
Double Trailers Refrigerated Freight Oversized/Overweight Automobile Hauler
Household Goods Containerized Freight Mobile Home Hauler
Hazardous Materials (please complete section IV) Other:
18) Is a bill of lading, shipping receipts or contract of carriage used for each shipment? Yes No
a. If yes, please provide a specimen. If no, please attach an explanation.
II. OPERATIONS
Page 3 of 8
19) Do you ever transport cannabis or cannabis byproducts? Yes No
Attach additional details for “yes” to a. or “no” to c.-e. below as well as a narrative of the types of cannabis goods you
transport:
a. If yes, are drivers permitted to take cash or inventory home? Yes No
b. Are firearms or other weapons allowed in the vehicle? Yes No
c. Do all vehicles have lockboxes bolted to the vehicle? Yes No
d. Do vehicles have interior and exterior cameras? Yes No
e. Are all vehicle or trailer bodies completely closed and equipped with snap locks? Yes No
f. What is the maximum value of cannabis that will be hauled?
20) Please complete the following regarding commodities hauled:
PROPERTY
PERCENTAGE
VALUE
Fresh Produce
Dry Grocery
Canned Goods
Meat, Poultry, or Seafood
Frozen Foods
Dairy Products
Eggs
Plastic Goods
Paper Products
Alcoholic Beverages (all Types)
Automobiles and Motorcycles
Recreational Vehicles
Pharmaceuticals
Nutraceuticals
Veterinary Medications
Cannabis or Cannabis Derivatives
Tobacco
Chemicals
Clothing
Textiles or Silks
Furs or Fur-trimmed Garments
Computers or Laptop Computers
Consumer Electronics
Cosmetics or Perfumes
Explosives
Firearms
Plants, Seedlings, and Cut Flowers
Mobile or Modular Homes
Live Animals
Manufacturing Machinery
Contractors’ Equipment
Other Mobile Equipment
Page 4 of 8
Household Effects
General Dry Freight
Building Materials
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
TOTAL
100%
** GENERAL DRY FREIGHT CANNOT MAKE UP MORE THAN 5% OF TOTAL**
21) Do you pull driver Motor Vehicle Records (MVRs) prior to hire? Yes No
a. How frequently are MVRs pulled/checked after hire?
b. Are drivers required to have a minimum of two (2) years CDL experience prior to hire? Yes No
c. Are drivers subject to pre-hire and intermittent drug and alcohol testing? Yes No
d. Have any drivers ever been issued a citation for DUI/DWI? Yes No
e. Are drivers required to submit to an annual physical exam? Yes No
f. Do you perform background checks, including legal work status, criminal record, Yes No
prior employment verification and reference checks on all drivers? If no, please
attach an explanation.
22) What is the average age of your drivers?
a. What is the age of your oldest driver?
b. What is the age of your youngest driver?
23) Are drivers required to keep daily logs of driving and rest hours? Yes No
a. Are log-book hours kept electronically? Yes No
b. Have any of your drivers ever been investigated by you or a legal authority for Yes No
log-book record falsification or driving over the legally allowed number of hours
without a rest period? If yes, please attach an explanation.
24) Do you have a written employee handbook or formal safety guidelines? Yes No
a. How frequently are safety meetings held?
III. DRIVER AND VEHICLE SECURITY INFORMATION
Page 5 of 8
25) Do your motor vehicles have dashboard cameras:
a. Facing the driver? Yes No
b. Forward-facing the road? Yes No
c. Rear-facing the road? Yes No
d. With footage backed up to a cloud-based storage for no less than 30 days? Yes No
26) Are drivers permitted to make unscheduled stops during transport? If yes, please attach Yes No
an explanation.
27) Do you have a formal vehicle maintenance program/policy in place? Yes No
a. How often are vehicles given routine service (in miles or months)?
b. Is all servicing performed by a qualified mechanic? Yes No
28) Are loaded vehicles or unattached trailers ever left unattended? If yes, please attach an Yes No
explanation.
29) What security measures are in place in each vehicle? Check all that apply:
Active GPS Kingpin Locks Fire Extinguishers Exterior Cameras
Vehicle Theft Alarms Remote Engine Disabling Other:
30) Do you have any commodity-specific security measures or procedures? If yes, please Yes No
attach an explanation.
31) What class of Hazmat do you haul? Check all that apply:
N/A (no hazmat) Class 1 – Explosives
Class 2 – Gases (non-flammable, flammable & toxic) Class 3 – Flammable & Combustible Liquids
Class 4 – Flammable Solids, Combustible Materials, Dangerous When Wet Materials
Class 5 – Oxidizers and Organic Peroxides Class 6 – Toxic Materials and Infectious Substances
Class 7 – Radioactive Materials Class 8 – Corrosive Materials
Class 9 – Miscellaneous Dangerous Goods (describe):
32) Have you ever been cited by the Federal Motor Carrier Safety Administration (FMCSA) for Yes No
any violations of 49 CFR Parts 350-399, or subject to an investigation for possible violations?
If yes, please attach an explanation and copies of all pertinent documentation.
33) Have you ever had a serious hazmat incident requiring immediate telephone notification Yes No
to the appropriate federal reporting agency (NRC, NTSB, DOT, CDC)? If yes, please attach
an explanation and copies of all pertinent documentation.
34) When was your written plans to address security risks related to the transportation of Yes No
hazardous materials in commerce last updated?
a. Are all employees trained in the security protocols pertinent to their role before Yes No
they are allowed access to hazardous materials?
b. Have your plans been reviewed by an independent security consultant, law Yes No
enforcement or federal agency, or legal counsel?
35) Do you do your own monitoring of the emergency response telephone number on Yes No
your shipping papers?
IV. HAZARDOUS MATERIALS
Page 6 of 8
a. If no, do you have a valid, in-force contract with a service provider? Yes No
If yes, please list:
b. If no to 35) and a., are shipping papers provided by another company who is Yes No
responsible for the emergency response telephone number and hazard information
(such as the product manufacturer)?
c. Do you retain shipping papers for no less than 12 months? Yes No
d. Do you ever sign certification for shipping papers which you have not prepared? Yes No
e. Where are shipping papers stored in vehicles?
36) Do you know of any incidents not currently reported to insurance that may result in a claim Yes No
against you? If yes, please attach an explanation.
37) Have any of your drivers even been at-fault for an accident resulting in damages to cargo Yes No
or reportable on other covered motor truck cargo limits which you settled outside of
insurance? If yes, please attach an explanation.
a. Was the accident reported to law enforcement? Yes No
b. Was the accident reported to your commercial auto insurance carrier? Yes No
38) Claim Details (duplicate this page for all claims)
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Cargo Liability Contingent Cargo Trailer Interchange
Refrigeration Breakdown Commercial Auto - Liability Commercial Auto – Phys. Damage
Commercial General Liability Transportation Pollution Liability Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the commodities
lost, and steps taken following the incident to mitigate loss and evaluate the claim. Please note “attached” and
include an additional sheet if the details do not fit below:
d. If this claim is closed, did it settle before trial? Yes No
e. If this claim is open, is a hearing, trial or arbitration date set? Yes No
+ If yes, when?
f. Were any of your procedures, rules, or standard equipment changed after this incident? Yes No
g. Was all cargo lost/the full value of the bill of lading or shipping receipt claimed? Yes No
+ If no, what percentage was lost? %
h. Total damages claimed: $
i. Claim total: $
V. CLAIMS HISTORY
Page 7 of 8
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: 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.
NOTICE TO KENTUCKY APPLICANTS: 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.
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 subject to fines and confinement in prison.
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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
Page 8 of 8
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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MOTOR TRUCK CARGO SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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