LOSS EXPERIENCE
Provide prior insurance carriers information for past full three years.
Policy Term Premium Total Amount Claims Paid & Reserves
From To
Insurance Company Name
No. of Motor
Powered
Vehicles
No. of
Accidents
Liab Phys Dam BI PD Comp/Coll Other
/ / / /
/ / / /
/ / / /
30. Is any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coverage
sought in this application?
Yes No If yes, provide complete details
31. Have you ever been declined, cancelled or non-renewed for this kind of insurance? Yes No If yes, date and why
CARGO INFORMATION
100% co-insurance clause applies. Use Tow Truck Supplement for in-tow/on hook coverage.
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
/ / / /
/ / / /
/ / / /
Describe Cargo Hauled % of Hauling Maximum Value Average Value Limit of Insurance Deductible
SEE PHYSICAL
DAMAGE
COVERAGE
SECTION
$500
$1,000
$2,500
Other
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.
32. Select Type of Cargo Coverage Desired:
Named Perils or Broad Form
33. Additional Coverage Options (additional premium may apply):
Additional Insured Endorsement (Lessee) Loading and Unloading Coverage
Earned Freight Coverage Refrigeration Breakdown Coverage Hired Car Cargo Coverage Exclude Theft Coverage
FILING INFORMATION
34. Is an FHWA filing required? Yes No If yes, MC number
Common Contract Broker Do you require FHWA cargo filing? Yes No
35. If you hold a broker’s license, identify name filed with FHWA, FHWA docket no. and receipts from brokerage operations
36. If you are an interstate regulated carrier, identify your registration or base state
37. Is an intrastate filing needed? Yes No If yes, show state and permit number
List states for which insured requires CARGO FILINGS (check name on permits)
38. Show exact name and address in which permits are issued
39 Is MCS 90 endorsement needed? Yes No
40. Is our policy to cover all vehicles owned, operated or under lease to applicant?
Yes No If no, explain
41. Are oversize/overweight commodities hauled? Yes No If filing required, show states
Are escort vehicles towed on return trips? Yes No
42. Does your authority allow for transportation of hazardous commodities?
Yes No
43. Do you allow others to haul hazardous commodities under your authority?
Yes No
44. Have you ever changed your operating name? Yes No Do you operate under any other name? Yes No
45. Do you operate as a subsidiary of another company?
Yes No
46. Do you own or manage any other transportation operations that are not covered?
Yes No
47. Do you lease your authority?
Yes No Do you appoint agents or hire independent contractors to operate on your behalf? Yes No
48. Have you purchased, sold or applied for authority over the past 3 years?
Yes No
49. Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.)?
Yes No
50. Is evidence/certificate(s) of coverage required?
Yes No
51. Please explain any "yes" answer to Questions 44 through 50
52. Do you have agreements with other carriers for the interchange of equipment or transportation of loads? Yes No
If yes, attach a copy of current agreements and complete the following:
(a) With whom has such agreement(s) been made?
(b) Do the parties named in (a) carry automobile liability insurance? Yes No
If yes, name of insurance company and limits of liability (bodily injury & property damage)
(c) Under whose permit does each of the parties to the agreement(s) operate?
(d) Is there a Hold Harmless in the agreement(s)? Yes No
53. Do you barter, hire or lease any vehicles?
Yes No If yes, explain
M-5551 MI (12/2010) Truck Application Page 3 of 4
