Fillable VIRGINIA TRUCK APPLICATION 1-10 Power Units Business Phone (Risk Placement Services, Inc.)

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VIRGINIA TRUCK APPLICATION 1-10 Power Units Business Phone (Risk Placement Services, Inc.)

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TRUCK APPLICATION
Entire Application Must Be Completed and Signed
1-10 Power Units
VIRGINIA
GENERAL INFORMATION
Name
Individual
Corporation
Partnership
LLC
Other:
Submission Number:
Proposed Effective Dates: FROM:
TO:
Mailing Address
City
State
ZIP Code
Business Phone
E-Mail Address
Garaging Address
City
State
ZIP Code
(if different)
OWNER/PRINCIPAL
Owner Name (First, Middle, Last)
Home Address
City
State
ZIP Code
Business Phone
SS # of Owner
Apt. #
Tax ID: Federal ID # or SS #
U.S. DOT #
Yrs. Applicant has been Operating Under Business Name
Safety Contact Person Name
Contact's Phone
Safety E-Mail Address
DESCRIPTION OF OPERATIONS
Commodity (Check any that apply)
For Hire
Private
Non-Trucking
Other:
Commodity
Type of Operation
Refuse/Waste/Garbage
Hazardous Materials requiring $1,000,000 Liability limits or less
Hazardous Materials requiring Liability limits higher than $1,000,000.
% of Loads
Max. Value
Commodity
% of Loads
Max. Value
Explain:
Range of Transport
Operations Less than 300 Mile Radius - List City Destinations Below
Interstate Intrastate
Operations Beyond 300 Mile Radius - Identify Metropolitan Areas Traveled Through or Into
Cities other than above or regular routes:
Atlanta
Balt.-Washington
Boston
Buffalo
Charlotte
Chicago
Cincinnati
Cleveland
Dallas/Ft. Worth
Denver
Detroit
Hartford
Houston
Indianapolis
Jacksonville
Kansas City
Little Rock
Los Angeles
Louisville
Memphis
Miami
Milwaukee
Mpls./St. Paul
Nashville
New Orleans
New York City
Oklahoma City
Omaha
Orlando
Philadelphia
Phoenix
Pittsburgh
Portland
Richmond
St. Louis
Salt Lake City
San Diego
San Francisco
Seattle
Tampa
Tulsa
Percent of Loads:
0 - 200
201 - 300
301+
Longest Trip One Way:
Miles
NL-193 VA (11/11)
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16
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
$$
Yes
No
Yes
No
Location(s)
# Units
Address, City, State
1.
Are filings required? If yes, complete
Filing Information
form. MC #
2.
Do you act as a freight-broker or freight-forwarder or arrange loads for others?
If yes, provide Brokerage Name:
MC #
Annual Brokerage Revenue
3.
Is all equipment operated under the applicant's authority scheduled on the application?
a.
If no, attach explanation.
b.
Indicate % of loads brokered by you to others:
4.
Is all owned equipment scheduled on this application? If no, attach explanation.
5.
Do you lease your vehicles to others?
If yes, who must provide primary liability coverage?
You
Lessee
6.
Do other motor carriers or owner-operators haul for you?
If yes, complete questions below, complete Hired Autos Application Supplement and attach copy of
lease agreement.
If no, skip to question #7.
A.
Name on the Bill of Lading:
Yours
Others
B.
On what basis are they leased?
C.
Provide annual cost of hire or # of trips
D.
Are vehicles leased with driver?
E.
Are leased vehicles included in this application for insurance?
(1)
If yes, do you require leased vehicle owners to purchase
non-trucking liability coverage?
(2)
If no:
a.
Is there a written lease agreement stating the lessor will
provide primary auto liability coverage while leased to you?
b.
Limit of Liability required
c.
Do you secure evidence the lessor has primary auto liability
coverage?
d.
Does the lease state that the lessor agrees to provide you with
30 days advance notice if their insurance coverage is being
cancelled or reduced?
7.
Do you pull doubles?
Triples?
8.
Do you haul intermodal containers?
9.
Is any portion of your operation seasonal? If yes, explain.
10.
Do you use any team, hot seat, slip seating or relay driver operations?
11.
Do you allow passengers other than company employees? If yes, attach copy of passenger program or
explain program (frequency, requirements), etc.
12.
Do you operate more than one terminal? If yes, provide the following:
Permanent
Basis
Temporary/
Trip Basis
Yes
No
13.
Do you sign contracts with shippers that give the shipper the right to determine cargo salvage values or
declare cargos a total loss regardless of actual damage in the event of a loss? If yes, attach a copy of the
contract.
14.
Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor
vehicle insurance law in the state where it is licensed or principally garaged? If yes, and need Liability
Coverage, complete Mobile Equipment Supplement.
15.
Do you require use of escort vehicles?
If yes, and escort vehicles are
not included
in this application for insurance, provide the name of the
insurance carrier, policy number and auto liability limits.
If yes and the escort vehicles are
included
in this application, drivers of escort vehicles should be listed in
the Driver information section.
16.
Do you haul over size, over weight loads? If yes, attach explanation.
Use N-3077 if additional space is needed for Driver Information, Insurance History, Schedule of Autos or Additional Interests.
NL-193 VA (11/11)
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26
DRIVER INFORMATION
(Last, First, Middle)
Date of Birth
License Number
State
Must be Completed for All Drivers
Date of Hire
# Violations/
Past 3 Years
Minor
Major
#
Driver Name
Accidents
Convictions
# Yrs.
Driving
Similar
Equip.
Accident
Amount of Accident
Description
Date of
DRIVER LOSS HISTORY - Past 3 Years
Driver Name
(Last, First, Middle)
DRIVER EMPLOYMENT HISTORY
Prior Employment and Full Address
Employment
of Unit
Driver Name
(Last, First, Middle)
Dates of
Type
If you have not had insurance for the past two years in your name, provide three years employment history for each driver.
(Use form TF-079 for additional drivers.) Do not indicate "self-employed" unless you have had insurance in your name.
DRIVER HIRING, TRAINING AND SAFETY
Yes
No
1.
Which of the following is part of your driver screening/hiring process:
Employment background check
Pre-employment drug test
Criminal background check
Road test
Motor vehicle record (MVR) review
Pre-employment Screening Program (PSP) Report from FMCSA
2.
Which of the following is part of your driver performance management process:
Annual review of driver's driving record (MVR)
Review of electronic engine data
Periodic review of driver and vehicle out-of service
Incentives for violation-free and accident-free driving
violations (SafeStat/CSA Reports)
Formal corrective action procedures
Periodic review of accidents/incidents
Driver safety training
3.
Do you adhere to a written vehicle inspection and maintenance program?
If yes, describe or attach program:
REVENUE AND MILEAGE
Past 12 Months
Units
Revenue Per Unit
Next 12 Months
Mileage Per Unit
Total Revenue
Total Mileage
INSURANCE HISTORY AND LOSS EXPERIENCE
Effective Dates
From - To
Prior Carrier Name
Policy Number
# Units
Insured
#
Losses
Loss Amount
Driver Involved in Loss
Yes
No
Prior Carrier
Coverage
Type*
1.
Has an insurance company cancelled or non renewed your policy in the last 3 years?
If yes, explain:
2.
Prior years insurance under business name:
Primary Auto Liability:
Non-Trucking Auto Liability:
Physical Damage:
Cargo:
3.
Indicate other company name(s) you have operated under in the last 3 years:
Company Names:
Insurance Provider(s):
4.
Provide 3 years Prior Carrier Information. Hard copy loss runs must be provided for risks with 5 or more power units.
*Type: P=Phys. Dmg. C=Cargo L=Prim. Liab. N=Non-Trk. Liab.
NL-193 VA (11/11)
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36
SCHEDULE OF AUTOS
All units you own or are leased to you must be scheduled and insured if filings are to be made. If you have more than 10
power units, form N-2379 VA, Virginia Fleet Application, must be completed.
To ensure Electronics (as defined by the policy), along with tarps, chains or binders are covered, include the value in each
auto's stated value.
FINANCED VALUE COVERAGE
- The Stated Limit of each auto must be equal to or greater than the outstanding financial
obligation for that auto in order for the Financed Value Coverage to apply.
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Owner's Name
Make
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Owner's Name
Make
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Owner's Name
Make
No.
Year
VIN Number
Unit ID
Vehicle Type*
Stated Limit
GVW/GCW
Radius
Owner's Name
Make
*Vehicle Type Legend
CCT - Car Carrier Trailer
CON - Container (Intermodal)
CUS - Curtain Side
DOL - Dolly, Con Gear
DRP - Drop Deck, Gooseneck
DPS - Dump Side
DPB - Dump Trailer (Bottom)
DPE - Dump Trailer (End)
FLT - Flat Bed
HOP - Hopper/Grain
LWF - Live/Walking/Floor
LIV - Livestock
LOG - Log
LOW - Lowboy
MEQ - Mobile Equipment
PUL - Pull Trailer
PUP - Pup Trailer
SEM - Semi Trailer
TAN - Tandem
TAT - Tank Trailer
TAA - Tanker Asphalt/Hot Oil
TAC - Tanker Chemical/Acid
TAG - Tanker Gasoline/Fuel
TAL - Tanker LPG
TAP - Tanker Pneumatic/Dry Bulk
TAO - Tanker-Other
NOC - Trailers Not Otherwise Classified
TRC - Tractors
TRK -Trucks
VAD - Van Trailer (Dry)
REF - Van Trailer (Temp Control)
ADDITIONAL INTERESTS
Unit #
Address
State
Name
City
ZIP Code
AI Type*
AI Type*
AI - Additional Insured LP - Loss Payee
LE - Employee as Lessor AL - Lessor-Additional Insured and Loss Payee
NL-193 VA (11/11)
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46
COVERAGES
AUTO LIABILITY
LIABILITY FOR NON-TRUCKING USE
EMPLOYERS NONOWNERSHIP LIABILITY
Number of Employees
Leased to:
HIRED AUTO LIABILITY
Limits:
PHYSICAL DAMAGE DEDUCTIBLES
Comprehensive
Collision
Specified Causes of Loss
Provide a Copy of Agreement
Maximum Trailer Value:
# Trailer Days per Power Unit:
OR
# of Power Units Under Agreement:
Cost of Hire
CSL
Limits:
CSL
TRAILER INTERCHANGE
AUTO LOAN/LEASE GAP COVERAGE
Selected Units
All Units
Limit
DELUXE
CARGO
Deductible
Hired Auto Cargo
COMBINED DEDUCTIBLE
Coverage included unless declined.
Decline Combined Deductible
RENTAL REIMBURSEMENT
Selected Units OR
All Units
Cost of Hire:
Days of Coverage:
30
120
HIRED AUTO PHYSICAL DAMAGE
Complete and Attach Supplement
OPTIONAL CARGO COVERAGES: (Check all that apply)
ENDORSEMENT
Temperature Control
Aluminum, Copper
Additional Earned Freight Increase Limit to $5,000
Electronics
Hard Liquor
Pharmaceuticals
Amount Per Day:
COVERAGE
REPORTING BASIS:
Revenue
Mileage
Units
UNINSURED / UNDERINSURED MOTORIST AND MEDICAL EXPENSE AND LOSS OF INCOME BENEFITS
UNINSURED MOTORIST (INCLUDES UNDERINSURED)
MEDICAL EXPENSE BENEFITS
LOSS OF INCOME BENEFITS
Limits: $100 per week
Coverage and limit choices in this section are for quoting purposes only. A separate Northland Insurance Company
Supplemental Uninsured Motorists / Underinsured Motorists, Medical Expense and Loss of Income Benefits Application(s)
must be completed and signed by the applicant when binding coverage.
For information about how Northland compensates its agents, brokers and program managers, please visit this website:
http://www.northlandins.com/Producer_Compensation_Disclosure.asp
If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance
Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102.
This application, including any material submitted in conjunction with the application or any renewal, does not amend the
provisions or coverages of any insurance policy or bond issued by Northland. It is not a representation that coverage does
or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and
circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of
coverage referenced in this document can depend on underwriting qualifications and state regulations.
SIGNATURES
I authorize Northland Insurance Companies to obtain a copy of any Motor Vehicle Report for rating/underwriting the
insurance for which I have applied. I also understand that a routine inquiry may be made providing information concerning
my character, general reputation, personal characteristics and mode of living. Upon written request, information as to the
nature and scope of the report will be provided to me.
Disclosure:
In connection with this application for commercial automobile insurance, we may review a credit report or
obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third
party in connection with the development of the insurance score. The credit report/credit-based insurance score will not be
used for any purpose other than the underwriting of the commercial automobile insurance policy for which you have applied.
I authorize Northland Insurance Companies to obtain a credit report, including but not limited to a credit-based insurance
score based on personal information provided. This authorization is valid for future reports obtained for renewal policies
with Northland Insurance Companies.
NL-193 VA (11/11)
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56
I hereby certify that the foregoing statements and answers are a just, full and true exposition of all the facts and
circumstances with regard to the risk to be insured, insofar as same are known to me, and the same are hereby made as the
basis and condition of the insurance.
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 and denial
of insurance benefits.
By signing below, I affirm full knowledge of and adherence to current D.O.T. Safety Regulations, and
hereby apply for insurance with respect to the coverages stated herein.
APPLICANT'S SIGNATURE
DATE
APPLICANT'S PRINTED NAME
APPLICANT'S TITLE
PRODUCER'S SIGNATURE
PHONE #
FAX #
NL-193 VA (11/11)
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66
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VIRGINIA TRUCK APPLICATION 1-10 Power Units Business Phone (Risk Placement Services, Inc.)

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Completed 23 November 2020

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