Truck Transportation Application
Agent Information
Date Received
Agency
Producer
Effective Date
Requested Quote Date
General Information
Named Insured
Street Address
State
Phone
Additional Named
Insureds
DBA
City
Zip
Fax
Affiliated
Companies
Personnel
Position
President
Operations Manager
Safety Director
Loss Control Contact
Insurance Contact
Operations
FEIN #
MC #
DOT #
Years in
Business
Years under
current mgmt
Name
Years
Business Type
Sole Proprietor
Corporation
Partnership
Carrier Type
Common
Contract
Private
Other
Other
If ‘other’,
If ‘other’,
please explain
please explain
Are you a
Yes
No
If ‘yes’, please
subsidiary?
explain
Do you operate as a broker?
Yes
No If ‘yes’, what is the MC number?
Do you travel into Canada?
Yes
No If ‘yes’, please list province(s) and mileage
Filings Requested:
BMC91X
Form E
All Needed State Filings:
Applicable states:
APP-TRKRS-01 0118
OS32
UIIA
% of Ownership
Terminal Locations
# Address, City, State
1
2
3
At each location:
# of employees
# of units
Fenced
Lighted
Security Guard
Video Surveillance
Controlled Entrance
Fenced
Lighted
Security Guard
Video Surveillance
Controlled Entrance
Fenced
Lighted
Security Guard
Video Surveillance
Controlled Entrance
Fenced
Lighted
Security Guard
Video Surveillance
Controlled Entrance
$ of fleet value
4
Square footage of office:
Are you involved in any busines other than trucking?
Yes
No
Do you provide service to vehicles other than your
own?
Yes
No
Square footage of garage:
Do you lease property or equipment
to others?
Do you have any storage facilities?
Projected and Historical Exposures
Radius
0 to 50 miles
51 to 200 miles
201 to 500 miles
501+ miles
Period
Projection
Current Year
1st Prior Year
2nd Prior Year
3rd Prior Year
4th Prior Year
%
No
Yes
No
Areas
East Coast
Midwest
Northeast
Southwest
Southeast
Northwest
West Coast
What is your average length of haul?
What is your maximum length of haul?
Metro Areas?
Yes
No
Major cities entered:
Revenue Units*
Yes
Total Revenue
Total Mileage
*Please attach a vehicle schedule including year, make, model, full VIN, and stated value for physical damage.
Revenue Definition: Revenue includes the total amount of money to which you are entitled to for the shipment of goods or property during the policy
term.
Mileage Definition: Mileage is the total number of loaded and unloaded miles by vehicles operating under your authority.
Commodity Information- attach additional paper as necessary
Type
1
2
3
4
5
6
7
8
9
10
Max Value
Avg Value
Do you haul hazardous materials?
Do any of your loads require placarding?
Do your trucks have alarm or theft protection?
Do any of your commodities require temperature
control?
Do you haul double or triple trailers?
Do you have any terminal exposure for cargo?
Do you do any containerized cargo hauling?
Do you have any oversize-overweight operations?
Do you have brokerage authority?
Any team operations?
% of Total
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Major Shipper
Please explain ‘yes’ answers
% of revenue:
If ‘yes’ how many
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APP-TRKRS-01 0118
Equipment – owned or leased and operated by insurd’s employees, officers, partners or owners.
Company Owned Equipment
Power Units
Tractors
Heavy Trucks
Medium Trucks
Light Trucks
Pickups
PP Auto
Other
Total Value
#
Trailers
Flatbed
Dry Van
Hopper
Dump
Tank
Reefers
Other
#
Total Value
Does Equipment supervision include:
Yes
Computerized Engines
Yes
Satellite Tracking (GPS)
Yes
Anti-Lock Brakes
Yes
Safety Decals
Yes
Specialized Lighting
Yes
Cell Phones
Yes
Radio Dispatch
Yes
Recording Devices
No
No
No
No
No
No
No
No
Owner Operator Equipment
Power Units
Tractors
Heavy Trucks
Medium Trucks
Light Trucks
Pickups
PP Auto
Other
#
Total Value
Trailers
Flatbed
Dry Van
Hopper
Dump
Tank
Reefers
Other
Total Value
Are any vehicles allowed to be used for
personal use?
Are Owner/Operators required to carry NTL?
Do you rent or lease to others?
Owner/Operator mileage in IFTA reporting?
Electronic Logging Devices Implemented?
If No to above, is action plan in place?
Please Describe:_______________________
Driver Information – please attach Driver Schedule
Fleet Drivers
Employees
Part Time
Casual
Leased
Owner-Operator
Sub Haulers
Drivers Hired
# replaced
# increased
Pay scale
Union
Non-Union
Wage Base
Hours
Miles
Revenue
Trip
Other
Driver Experience required
# of years
# of miles driven
Driver Age
# of drivers under 25
# of drivers over 65
MVR Review
New Hires
Annual Review (all drivers)
Complete driver files available?
Who administers your driver hiring process?
What is the length of your driver training program?
Is the program required for all drivers?
Are owner/operators subject to insured’s hiring standards?
Are owner/operators subject to insured’s maintenance standards?
Are driver files updated annually?
What is the disciplinary action for drivers that develop unacceptable
records?
Do you require Owner/Operators to carry Workers Compensation insurance?
#
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Check all that apply
Driver selection procedures
Written Application
Reference Checks
Written Test
Road Test
MVR Check
Pre-Hire Physical
Interview
Drug Test
Criminal Background Check?
Does Indoctrination include:
Company rules and procedures
Daily vehicle inspections
Equipment familiarization
Route familiarization
Emergency procedures
Accident reporting procedures
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Page 3 of 8
APP-TRKRS-01 0118
Safety and Maintenance – include any safety and maintenance programs
Who is responsible for safety?
Do you use a safety awards program?
If ‘yes’, please describe.
How often are saftey meetings held?
Are safety meetings mandatory?
Do you maintain an accident register?
Do you allow guest passengers?
If ‘Yes”, is there a current, in-force
passenger accident policy? (Please
provide a copy)
Preventive Maintenance
Who is responsible for maintenance?
Is a record kept on each vehicle?
Controlled inspection frequency?
Daily vehicle inspection reports?
Are front axle brakes operative on all units?
Your maintenance program services:
Company Vehicles
Owner/Operators
Others
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Vehicle Maintenance is:
Internal
External
Both
Do you have any of the following onsite:
Parts Department
Service Bays
Body Shop
Are owner/operator vehicles subject to the same
maintenance program as owned equipment?
Number of mechanics on staff?
Annual mechanic payroll?
Who services leased vehicles?
If you do not have a maintenance facility, please
describe how vehicles are serviced.
Leasing Supplement
Do you lease equipment to others on a long term basis?
What revenue do you derive from this equipment?
-Attach copies of Lease agreements
Do you allow trip leasing under your authority?
-% of revenue derived?
-If ‘yes’, do you require a Hold Harmless agreement?
Are certificates of insurance on file?
Are Permanent/exclusive lease agreements used?
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Underwriting Questions
Has your insurance been non-renewed or cancelled in the past 5 years?*
*(Missouri Applicants, DO NOT ANSWER THIS QUESTION)
Have you filed for bankruptcy in the past 5 years?
Do you ever haul noxious, caustic, toxic, flammable or explosive commodities?
Do you haul any waste?
Do you have any interline, interchange, or intermodal agreements?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Please describe any ‘yes’ answers:
Page 4 of 8
APP-TRKRS-01 0118
Auto Liability Coverage
Auto Liability
Hired and Non-Owned Auto
Personal Injury Protection
Uninsured Motorists
Medical Payments
Physical Damage
Comprehensive
Specified Perils
Collision
Total Insured Value of Fleet
Coverage Request Summary
Limit Requested
Deductible
Deductible
Current Carrier
Current Carrier
Do you require more than $1,000,000 of catastrophic coverage?
Expiring Premium
Expiring Premium
Yes
No
Trailer Interchange
Limit Requested
Deductible
Current Carrier
Yes
No
1000
In the event of a loss, trailer interchange agreements will be required.
# of trailers:
# of days per year:
Explain Any Coastal Exposures / Garaging:
Expiring Premium
Motor Truck Cargo
Per Vehicle
Catastrophe Limit
Terminal Limit
Expiring Premium
Limit Requested
Deductible
Current Carrier
Do you require a limit greater than $250,000 for any coverage?
Are any loaded trailers stored at any terminal over 72 hours?
Do you require refrigeration Breakdown coverage?
General Liability Coverage Limit Requested
Deductible
Aggregate Limit
Per Occurrence Limit
Per Location Limit
Per Policy Limit
Employee Benefits Liability
Payroll other than Driver
Coverage for all locations
-please include supplemental General Liabilty application.
Yes
Yes
Yes
No
No
No
Current Carrier
Does the insured have any operations other than trucking, such as:
1. Storage of goods of other (warehousing)?
2. Storage of vehicles of others?
3. Space leased to others?
4. Freight forwarding or consolidation for others?
5. Any other non-trucking operations? If yes, please provide details:
6. Mobile Equipment; i.e. snowplows, forklifts, cranes, cherry pickers,
yard goats, etc.? If yes, please provide details:
7. Does applicant sponsor or participate in racing events?
8. Is there an on-site fueling and/or storage of fuels, chemicals, or other products
9. Is there a truck wash on-site?
Expiring Premium
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Page 5 of 8
APP-TRKRS-01 0118
Submission Requirements
•
•
•
•
•
•
•
Completed AmTrust Application – signed, including UM/UIM & PIP forms. Other applications will be accepted
provided they contain the required underwriting information.
Current drivers list including:
o Date of birth, Date of hire, license #/SSN.
o MVRs are required for all drivers.
 25% random sample is acceptable for fleets greater than 50 units with the balance required at
binding.
 MVRs must be no older than 60 days.
o All drivers must meet eligibility guidelines.
Current vehicle schedule including: year, make, model, complete VIN, and stated value (if requesting APD).
Current financial statements, income statement & balance sheet, for current & first previous year. Audited
financials are preferred, but not required.
Five (5) years of currently valued loss runs for all requested lines, issued within 90 days of expiration.
IFTAs fuel tax reports for the last 4 quarters (8 preferred). If fuel tax reports are not available for the risk,
supplemental mileage information must be provided.
Account narrative describing operations, customers & commodities, and regular routes of travel to better explain
insurable exposures.
The Applicant hereby certifies that the information contained in this application is true and agree that a
misrepresentation of any of the facts will constitute reason for the Company to void or cancel any policy issued on the
basis of this application and will hold the company harmless for the action taken. The Applicant also agrees that if a policy
is issued pursuant to this application, the application and any elections or rejections which are included with the
application and signed, may be relied upon by the Company as accurate.
The Applicant also understands that an inquiry may be made that will provide information concerning general reputation,
financial stability and other pertinent financial data, credit history, driving experience, vehicle usage, and other
information in determing whether the Company offers a quote. The Applicant authorizes the Company to obtain such
reports in connection with this Applicant.
The Applicant also recognizes that all or part of the operation are subject to Department of Transportation oversight
requiring adherence to rules and regulations. The Applicant acknowledges that DOT rules and regulations are understood
and adhered to, including, but not limited to, driver hiring, vehicle inspection, maintenance and hours of service.
Fraud Warning Disclosures
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent
claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance
is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of
the third degree)*. *Applies in FL Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares
with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any
written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for
personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial
or personal insurance which such person knows to contain materially false information concerning any fact material
thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act.
Page 6 of 8
APP-TRKRS-01 0118
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is
a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value
of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA: 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. *Applies in ME Only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by
submitting an application containing a false statement as to any material fact may be violating state law.
Notice of Information Practices (Privacy)
Personal Information about you, including information from a credit or other investigative report, may be collected from
persons other than you in connection with this application for insurance and subsequent amendments and renewals.
Such information as well as other personal and privileged information collected by us or our agents may in certain
circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to help
determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection
with the development of your score. You may have the right to review your personal information in our files and request
correction of any inaccuracies. You may also have the right to request in writing that we consider extraordinary life
circumstances in connection with the development of your credit score. These rights may be limited in some states.
Please contact your agent or broker to learn how these rights may apply in your state or for instructions on how to submit
a request to us for a more detailed description of your rights and our practices regarding personal information.
Applicable in AZ: As described in ARIZONA revised statute 20-2104(D), a credit report or other investigative report about
you may be requested in connection with this application for insurance. Any information which we have or may obtain
about you or other individuals listed as policyholders on our policy will be treated confidentially. However, this
information, as well as other personal or privileged information subsequently collected, may under certain circumstances,
be disclosed without prior authorization to non-affiliated third parties. We may also share such information with affiliated
companies for such purposes as claims handling, servicing, underwriting and insurance marketing. You have the right to
see personal information collected about you, and you have the right to correct any information which may be wrong.
Also, pursuant to ARIZONA revised statute 20-2104(C), if you are interested in obtaining a complete description of our
information practices, and your rights regarding information we collect, please write us at the address provided with your
policy.
Applicable in CA: This authorization shall expire one year from the date you signed the authorization.
Applicable in MA: Credit scoring information may be used to determine your eligibility for insurance but not for rating
purposes.
Applicable in MN: We are required to obtain this authorization from you pursuant to Minnesota Statute 72A.501. I, the
undersigned, hereby authorize the agent named above, if any, and/or the underwriting department of the insurance
company named above to collect credit-related and other information about me from credit bureaus and other
organizations providing personal or privileged information. I understand this information will be used for the purpose of
making underwriting decisions in connection with the insurance for which I have applied, sought reinstatement or
requested a change in benefits. These decisions may include determinations to grant or deny me coverage and/or the
rates I will be charged. I also understand that I have the right to request in writing that extraordinary life circumstances
be considered in connection with the development of my credit score.
Applicable in OR: In connection with my application for insurance to the company shown above, ("You"), I hereby
authorize you to collect and disclose personal, privileged information, about me, by and to consumer reporting agencies,
your authorized representatives, assignees, agents and affiliates. The information collected and disclosed extends to my
credit standing, credit worthiness, credit capacity, personal characteristics and mode of living. I understand that credit
scoring information may be used to either determine my eligibility for insurance or the premium I will be charged. Credit
scoring cannot be used for renewals unless requested by the insured. I understand that I am entitled to receive a copy of
this authorization and, upon request, a record of any subsequent disclosures of personal or privileged information that
must include the name, mailing address and institutional affiliation of the party to which the information was disclosed as
Page 7 of 8
APP-TRKRS-01 0118
Applicable in OR cont.: well as the date of the disclosure, and to the extent practicable, a description of the information
being disclosed.
Applicable in VA: In accordance with applicable federal and state laws, a credit report or other investigative report about
you may be requested in connection with this application for insurance. Credit scoring information may be used to help
determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection
with the development of your score. You may request that your credit information be updated and if you question the
accuracy of the credit information, we will, upon your request, reevaluate you based on corrected credit information from
consumer reporting agency. Any information which we have or may obtain about you or other individuals listed as
policyholders on your policy will be treated confidentially. However, this information, as well as other personal or
privileged information subsequently collected, may, under certain circumstances, and where permitted by law, be
disclosed without prior authorization to non-affiliated third parties. We may also share such information with affiliated
companies for such purposes as claims handling, servicing, underwriting and insurance marketing. You have the right to
request in writing that we consider extraordinary life circumstances in connection with the development of your credit
score. You have the right to see personal information collected about you, and you have the right to correct any
information which may be wrong. If you are interested in obtaining a complete description of our information practices,
and your rights regarding information we collect, ask your agent, or if you have been issued a policy, please write us at the
address provided with your policy.
An insurer authorized to do business in certain states that uses credit information to underwrite or rate risks for a policy
of personal insurance may, on written request from a consumer, provide reasonable exceptions to the insurer's rates,
rating classifications, company or tier placement, or underwriting rules or guidelines for a consumer who has experienced
and whose credit information has been directly influenced by events considered extraordinary life circumstances such as:
1. Catastrophic event, as declared by the federal or a state government.
2. Serious illness or injury, or serious illness or injury to an immediate family member.
3. Death of a spouse, child, or parent.
4. Divorce or involuntary interruption of legally owed alimony or support payments.
5. Identity theft.
6. Temporary loss of employment for a period of three months or more, if such loss results from involuntary termination
of employment.
7. Military deployment overseas.
8. Other events, as determined by the insurer
If a consumer submits a request for an exception as set forth above, an insurer may, in its sole discretion, but is not
required to, do any of the following:
1. Require the consumer to provide reasonable written and independently verifiable documentation of the event.
2. Require the consumer to demonstrate that the event had direct and meaningful impact on the consumer's credit
information.
3. Require such request to be made no more than sixty days from the date of the application for insurance or the policy
renewal.
4. Grant an exception despite the fact that the consumer did not provide the initial request for an exception in writing.
5. Grant an exception where the consumer asks for consideration of repeated events or the insurer has considered this
event previously.
Signature
Agency Name:
Producer Name:
Date:
Producer Signature:
Applicant Name:
Applicant Signature:
Page 8 of 8
APP-TRKRS-01 0118