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Trucking Insurance Form
laxmikant
2020-09-01T05:02:14+00:00
Trucking Insurance
Step
1
of
4
25%
1. General Information
Name Of Applicant:
*
Full Description Of Operation:
*
Phone
*
Email
*
Website
Contact Name:
*
Title:
*
Years in business:
*
Years similar experience and with whom:
*
Gross receipts:
*
Does the applicant broker freight to other carriers? if so, revenue from this:
*
Current insurer and expiry date:
*
President (Name)
*
President (Time in Position in years or months)
*
Operation Manager (Name)
*
Operation Manager (Time in Position in years or months)
*
Claims Manager (Name)
*
Claims Manager (Time in Position in years or months)
*
Maintenance Manager (Name)
*
Maintenance Manager (Time in Position in years or months)
*
Additional Information Required to Quote (Check all that apply)
Vehicle Schedule
3-6 year loss run
IFTA / Fuel Tax Report
Driver List with Commercial Abstracts, see note *
Carrier Profile
Leased Operator Contract
2. Type of Operation
Common Carrier
Contract Carrier
Private Carrier
Corporation
Has any Insurer cancelled, declined, refused to renew or issue automobile, CGL or Cargo insurance to the applicant or any listed driver in the past 6 years?
Yes
No
3. Driver Information:
*
*please also attach recent MVRs for all below listed drivers
Name
Birth Date (DD/MM/YY)
Years driving vehicle type
Accident (Yes/No)
Driver’s License Number
Employed Date (DD/MM/YY)
Lease Operator (Yes/No)
Describe hiring procedures for all driver (testing/road supervision/record keeping:
*
4. Filings
Are filings required:
Yes
No
MC #
*
U.S. DOT #
*
5. Radius of Operations:
*IFTA reports may be required to quote risk
Further destination in Canada
*
Further destination in USA:
*
Does the applicant own or lease any US domiciled Vehicles? If yes, provide details:
*
Radius Chart
Total percentage Canadian KMs:
*
Total percentage USA KMs:
*
% within 250 km / Canada - Percentage (must add up to 100%)
*
% within 250 km / USA - Percentage (must add up to 100%)
*
% 251 – 750 km / Canada - Percentage (must add up to 100%)
*
% 251 – 750 km / USA - Percentage (must add up to 100%)
*
% 751 – 1,500 km / Canada - Percentage (must add up to 100%)
*
% 751 – 1,500 km / USA - Percentage (must add up to 100%)
*
% 1,501 – 4,000 km / Canada - Percentage (must add up to 100%)
*
% 1,501 – 4,000 km / USA - Percentage (must add up to 100%)
*
% over 4,000 / Canada - Percentage (must add up to 100%)
*
% over 4,000 / USA - Percentage (must add up to 100%)
*
6. Vehicle List:
Are all vehicles registered to the applicant
Yes
No
Truck and tractor schedule: (If the number of units exceed this space, please attach a separate schedule)
*
Unit
Year
Make / Model
Serial Number
Purchase Date DD/MM/YY
Owner Operator
Attached Machinery value & use
Identify any reefer units
*
Identify any unit with any attached machinery (e.g. crane or hoist): Click
*
Trailer schedule: (If the number of units exceed this space, please attach a separate schedule)
*
Unit
Year
Make / Model
Serial Number
Purchase Date DD/MM/YY
Owner Operator
Attached Machinery value & use
Identify any reefer units
*
Identify any unit with any attached machinery IE crane or hoist
*
Is non-owned trailer coverage required:
Yes
No
Max value per any one trailer:
*
Max number in the applicant’s possession at any one time?
*
Does applicant rent or lease to others:
Yes
No
If yes, explain
*
Does applicant employ any leased operators:
Yes
No
If yes, explain
*
Describe Telematics information including provider, ELogs / ELD / Driver Monitoring:
*
*Are the operators’ units registered to the applicant:
Yes
No
*Do operators provide their own insurance:
Yes
No
*Attach copy of leased operator’s contract
7. Cargo:
*
Commodity (Choose an item)
Average Load Value
Maximum Load Value
% of Load
Does applicant haul hazardous goods as defined by Hazardous Goods Act?
Yes
No
Does applicant haul any Cannabis or Products containing Cannabis?
Yes
No
Provide placard number(s):
*
Percentage of deliveries on a declared value Bill of Lading:
*
Can the driver see refrigeration warning indicators from inside the cab:
Yes
No
8. Security
Does the insured have a concentration of risks where several units may be parked together?
Yes
No
Check those that apply:
*
Fenced Yard
Locked Gate
Well Lighted
Watchman
Guard Dog
Security System
Fire Protection
Name and title:
*
Date
*
DD slash MM slash YYYY
9. Coverage Requirements:
Automobile
Third Party Liability (Limit) :
*
Third Party Liability (Deductible) :
*
Collision (Limit) :
*
N/A
Collision (Deductible) :
*
Comprehensive (Limit) :
*
N/A
Comprehensive (Deductible) :
*
All Perils (Limit) :
*
N/A
All Perils (Deductible) :
*
SEF 20 – Loss of Use – Per Occurrence (Limit) :
*
SEF 20 – Loss of Use – Per Occurrence (Deductible) :
*
SEF 40 (Limit) :
*
Included
SEF 40 (Deductible) :
*
SEF 44 (Limit) :
*
Included
SEF 44 (Deductible) :
*
Cargo
Cargo Limit Per Vehicle (Limit) :
*
Cargo Limit Per Vehicle (Deductible) :
*
Warehouseman’s Liability (Limit) :
*
Warehouseman’s Liability (Deductible) :
*
General Liability
General Liability (Limit) :
*
General Liability (Deductible) :
*
Tenants Legal Liability (Limit) :
*
Tenants Legal Liability (Deductible) :
*
Crane Lift Operator Liability (Limit) :
*
Crane Lift Operator Liability (Deductible) :
*
Max Per Occurrence Deductible (Limit) :
*
Max Per Occurrence Deductible (Deductible) :
*
Broker Commission 10% (Limit) :
*
Broker Commission 10% (Deductible) :
*
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