SUPPLEMENT TO TRUCK APPLICATION
CARGO COVERAGE APPLICATION
This Supplement is a part of the Application and will
be relied upon by the Company as an integral part of
the Application.
1. APPLICANT'S NAME
2. Has any company ever cancelled or refused to issue cargo insurance? G Yes G No
If yes, explain
3. Have you purchased cargo insurance in the past 3 years? G Yes G No
4.
PREVIOUS CARGO CARRIER AND LOSS EXPERIENCE (list for the past three years with most recent carrier first).
Policy Term
From To
Company & Policy Number Premium
Number of
Claims
Cause of Loss Amount Paid Reserves
5.
Type of Cargo % of Hauling Maximum Value Average Value
6.
Applicant desires to have cargo premiums applied to each:
G power unit
, which includes any trailers, semi-trailers, or mobile homes, but only while attached to a described power unit, or;
G trailers
or semi-trailers.
7.
INSURANCE NEEDS – Complete for desired coverages:
G Named Perils or G Broad Form Deductible Amount $
Limit of Insurance $
OPTIONAL COVERAGES (Additional Premium): G Additional Insured Endorsement (Lessee) G Loading and Unloading Coverage
G Earned Freight Coverage G Refrigeration Breakdown Coverage G Hired Car Cargo Coverage
REDUCTION OF COVERAGE (Premium Credit): G Exclude Theft Coverage
If applicant hauls double wide mobile homes, Limit of Insurance must be equal to the value of both sides combined to satisfy co-insurance.
Amount of insurance on each truck should equal maximum load carried, as policies contain 100% co-insurance clause.
8.
CARGO FILING INFORMATION:
List states for which insured requires CARGO FILINGS (check name on permits)
Is I.C.C. filing required? G Yes G No I.C.C. Docket Number
9.
MISCELLANEOUS:
THE INSURER CAN CANCEL THIS POLICY FOR WHICH YOU ARE APPLYING WITHOUT CAUSE DURING THE FIRST
90 DAYS. THAT IS THE INSURER’S CHOICE. AFTER THE FIRST 90 DAYS, THE INSURER CAN ONLY CANCEL THIS
POLICY FOR REASONS STATED IN THE POLICY.
M-4413a SC (12/2006)
