Motor Truck Cargo Application

Business information

Start with the US DOT number. We will retrieve available public carrier information so you can review and complete it.

1. Applicant: doing business as:

Company: Year established

Address:

MC / US DOT #

US DOT number

Applicant

Doing business as

Company

Year established

MC number

Address

Address line 2

City

State

ZIP code

Phone

Email

Website

FEIN

New venture

2. Names, addresses and functions of Associated or Subsidiary Companies to be included:

3. Are Companies: a) Common Carriers [ ] b) Private Carriers [ ]

Contract Carriers [ ] d) Owner of cargo [ ] e) Other [ ] (Please give details at end of form)

Common Carriers Private Carriers Contract Carriers Owner of cargo Other

Other company details

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

Released liability basis

Released liability details

Additional valuation rates

Approximate annual additional valuation charges

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)

Subcontracting basis and 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?

Subcontractors responsible and insured

Copies of current insurance maintained on file

Operations and revenue

Provide specific cargo and revenue information. Add only the rows that apply.

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
Total G.R. all operations is calculated from the two entered amounts.

6. List by category and percentage of the total loads shipped: General Freight etc. is not acceptable, please be specific.

7. The following interests are excluded under the basic policy form, but some excluded items may be covered with the prior agreement of Insurers at additional premium if requested. Please circle any you wish to be covered, and include details of such exposures in answer to question 6: 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, perfume, eau de toilette, diapers, baby formula, live animals, tobacco, cigars, cigarettes, ecigarettes, vapes, all forms of cannabis including but not limited to marijuana and hemp, nonferrous metal in scrap or ingot form, furs, all forms of alcohol intended for human consumption other than beer, 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 assembled consumer and commercial electrical appliances/equipment and unassembled electronic components, including but not limited to; radios, televisions, computers (including peripherals), consoles, computer and/or gaming software, hard drives, chips, microchips, printed circuit boards and their components, modems, monitors, cameras, facsimile machines, telephones (including cellular), pagers, photocopiers, printers, scanners, batteries, PDAs, VCRs, HI-FIs or stereos (including speakers/components), compact discs, MP3s, DVDs, minidisks, digital players and/or recorders. Battery operated or electrically operated toys with a unit value greater than USD75 shall be deemed to be electronics. Heavy electrical items such as switchgear, turbines, and generators, or kitchen appliances such as washing machines, dishwashers, microwave ovens, toasters, and irons shall not be considered to be electronics).

Additional excluded-interest or coverage details

8. Form of cover required: Reefer Breakdown? Yes [ ] No [ ]

Coverage form (online detail)

Reefer Breakdown?

Terminals and coverage limits

Tell us where cargo may accumulate and the limits required.

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 ?

On vehicles?

Off vehicles ?

If either answer is yes, please give details of any such places which are regularly used:

10. Limits required:

a) USD any one vehicle

b) USD any one loss (vehicle accumulation)

c) USD any one terminal (off vehicles)

If Limit for 10b) is in addition to 10c), specify overall loss limit needed USD

Do you ever carry loads valued greater than the cargo insurance limit requested? Yes / No

Requested deductible (supplemental online detail)

11. Give details of any steps taken to secure vehicles whenever left unoccupied.

12. Percentage of hauls by distance: 1-250 miles [ ] 251-1000 miles [ ] 1001+ miles [ ]

1-250 miles

251-1000 miles

1001+ miles

State filings required (supplemental online detail)

Vehicles

Add exactly the vehicles and trailers for which cargo coverage is required. The completed application calculates the category counts from this schedule.

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 Flatbed trailers Tank trucks Tank trailers Other power units Other trailers Total number of power units Total number of trailers

0 vehicles scheduled.

14. Please supply power unit Make, Model and Vehicle Identification Numbers if scheduled vehicle policy required: Please use a separate sheet if necessary.

Drivers

Add every driver. An MVR must be uploaded for each driver before signature can be requested.

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

0 drivers scheduled.

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?

Loss and insurance history

Enter each available year. Do not add empty schedule rows.

18. Please give details of your cargo loss experience whether insured or not, for the past 5 years, FROM 1st DOLLAR / VO DEDUCTIBILE

19. Are details of claims within deductibles (‘over, shortage and damage') maintained? If so, please give details for the past 3 years:

20. Has any insurer within the past 5 years refused to renew, or canceled insurance to the applicant?: If so please give details:

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:

Documents and signer

Upload loss runs unless this is a new venture, an MVR for each driver, a specimen waybill when released liability applies, and any miscellaneous supporting documents.

Document type

Driver for MVR

File

Description

No documents have been uploaded yet.

Applicant signer

The signer will receive an InterSign email with a one-time-passcode signing link.

Signer name

Signer email

Position

Location

Review and request signature

Review every step before requesting the electronic signature. Once requested, the application is locked and cannot be edited unless an underwriter reopens it.

23. 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

InterSign records the signature, date, signer identity, and evidence after the signer follows the secure email invitation.

Need Auto Physical Damage too? Start the Auto Physical Damage application with this same applicant record.

Save and resume

Email a private resume link to the applicant email entered on step 1.