Intermodal Fleet Application
Agent Information:
Agency Name:
Agency Address:
Producer Name:
Producer Email:
Producer Phone:
Requested Effective Date: Click here to enter a date.
Quote Need By Date: Click here to enter a date.
Applicant Information:
Name
Address
Mailing Address (if different)
Primary Telephone #
Co. Website Address
Years in Business
Under Current Management Since
Key Management Personnel:
President
Operations Manager
Business Type:
☐Corporation
☐Partnership
☐Proprietorship
Loss Control/ Safety
Other
Operating Authorities:
☐Common Carrier
☐Contract Carrier
☐Private Carrier
☐Brokerage
Key Numbers:
MC Docket#
US DOT #
State Docket
Federal Tax ID
State Tax ID
Describe The Business:
Operations
List All Terminal Locations:
Street
City
State
Number of Units
Cities/Ports Served/ Traveled From
Mileage &
Revenue
Current
1st Prior
2nd Prior
3rd Prior
4th Prior
5th Prior
Trucking
Revenue
Brokerage
Revenue
%
Cities/Ports Served/ Traveled To
Total Miles
Owned
Tractors
Owner
Op Units
Owned or
Leased Chassis
Radius - Indicate as a % what amount of your operations fall within the following:
0-100
%
101-300 Miles
%
301 to 500
%
500+
%
What is the average
What is the Max length of
length of haul?
haul?
Regular Route
%
Irregular Route
%
Contract Haul
%
Interstate Routes
Commodity Hauled
% Revenue
Average Value
%
Other
Trailers
%
Maximum Value
Do you haul any electronics, cigarettes, alcohol, tires, seafood, refrigerated cargo or any other high value cargo? ☐Y ☐N
If yes provide details:
Does supervision include use of recording devices, radio dispatch, satellite comm., cell phones, EOBRs? ☐Y
If yes provide details.
☐N
Driver Information
Attach a Driver List with matching MVRs Including the Following Information. The list should include all full and part time
company drivers and owner operators and other employees that may drive on a casual basis.
Name
DOB
DOH
YOE
YOE/Intermodal
# Moving Viol
#.Employee Drivers
#Owner Operators
#Sub haulers
#Other
Total
DOH <1 yr
DOH 1-2 yrs
DOH 2-5 yrs
DOH 5 + yrs
Total
Wages Based on:
☐Hours
☐Revenue
☐Miles
Driver Selection Includes Use of:
☐Pre-Hire Physical
☐Written Application
☐MVR Check
☐Written Test ☐Reference Checks
Driver Indoctrination Includes:
☐Familiarization w/equipment
☐Training in Handling Commodities
☐Trips
☐Other
☐Interview
☐Driving Test
☐Drug Test
☐PSP Report
☐With Routes
Length of Training Program?
Any driver training offered such as Defensive Driving, Smith or other systems? ☐Y
What are the Hiring Standards? Minimum Age
Violations in 36 months
☐Procedures for Accident Reports
☐Familiarization with Company Rules
Who Administers Driver Hiring Process?
☐N
Years of Experience
Accidents in Past 36 Months
# Accidents
YOE Operating like Equipment
Minimum Years driving in the U.S.
Owner/Operators
Are Permanent Lease Agreements Used?
☐Yes
☐No
Are Drivers Subject to Insureds’ Hiring Standards?
☐Yes
☐No
Are Trip Lease Agreements Used?
☐Yes
☐No
Are Driver Files Maintained by Insured?
☐Yes
☐No
Is Equipment Inspected by the Insured?
☐Yes
☐No
Are Owner Operators Included in Safety Meetings?
☐Yes
☐No
Are driver trainees used?
☐Yes
☐No
Are Team, slip seat, shift or relay drivers used?
☐Yes
☐No
Safety and Compliance
Safety Director
Other Duties
Describe Duties
☐Y
☐N
Employee Handbook?
Does it include driver qualifications and hiring standards?
☐Y
☐N
Do you provide orientation and training for new hires?
☐Y
☐N
Do you have a formal written safety program?
Are safety meetings held? ☐Y
☐N
☐N
☐Y
☐N
How often?
☐ Y ☐N
Mandatory Attendance including owner operators?
Interim training material used like videos, tapes, online instruction or outside instructors?
Do you use an outside safety consultant?
☐Y
☐Y
☐N
If yes, describe services:
Any safety award programs for safe driving?
☐Y
☐N
☐Y
☐N
Describe:
Any program in place dealing with drivers who have accidents or violations?
Describe:
☐Y
☐N
Do you run a motor vehicle report and complete background check prior to hire?
☐Y
☐N
Do you conduct an annual driver review of each drivers performance?
☐Y
☐N
Do you audit log books for hours of service compliance?
☐Y
☐N
Do you have a drug testing program?
☐Y
☐N
Do you have a vehicle inspection program?
☐Y
☐N
Do you have a scheduled vehicle maintenance program?
☐Y
☐N
Do you maintain an accident register and conduct periodic accident analysis?
☐Y
☐N
Are all owner operators required to carry at least $500,000 non-trucking liability?
☐Y
☐N
Are certificates on file?
☐Y
☐N
Is the insured listed as an additional insured?
☐Y
☐N
Are units governed? If yes what speed?
What is your policy regarding passengers?
If allowed, do they require waivers signed and passenger policy?
Which of the following are included in driver files?
☐Y
☐N
☐Application
☐Reference Checks
☐MVR Road Test
☐Disciplinary Warnings
☐Written Test
☐Copy of License
☐Accident Reviews
☐Physical Results
☐Training Records
☐PSP Report
☐Other
☐Y
Are driver’s files updated annually with information including new MVR?
☐N
Is there any current driver with convictions for DUI, DWI, failed drug or alcohol test, or reckless operations? ☐Y
☐N
What action is taken when drivers develop unacceptable records?
Maintenance
Do you have a maintenance program?
☐Y
☐N
Do you employ a maintenance manager?
☐Y
☐N
Maintenance program is for:
Vehicle maintenance is:
☐Company Vehicles
☐Engine
☐Body
Name?
☐Owner Ops
☐Brakes
☐Tires
☐other
☐Trucks
Is owner operator equipment subject to same program as owned equipment? ☐Y
Are pre-trip and post trip inspections made daily?
☐Y
☐Chassis
☐Other
☐N
☐N
Are files and records kept on all units including owner operators?
☐Y
☐N
If you do not have your own maintenance facility, describe the maintenance program for owned and owner operator
equipment:
Vehicles
Please attach a complete vehicle schedule listing all units owned, permanently leased, operated or hired
#. Vehicle Type
Truck Tractors
Trucks
PPTs
Trailers (inc non owned)
Chassis
Owned
Leased
Owner Operators
Stated Values
Insurance Program Requested
Coverage
Auto Liability
UM/UIM
Medical Payments
PIP
Hired Auto Liability
Hired Auto Physical Damage
Trailer Interchange
Collision
Comprehensive
Specified Perils
Cargo
Cargo Catastrophe Limit
Terminal Limit
Named Shipper
General Liability
General Aggregate
Products-Completed Ops
Personal Injury
Each Occurrence
Fire Damage
Medical Expense
Limits
Deductible
Exposure
Loss History
List all known and or reported losses for the current and past 4 years or attach detailed loss runs. Please include accident
loss information for Auto Liability, Auto Physical Damage, Cargo, and General Liability. Attach a summary if additional space
is needed.
Policy
Term
From To
Insurance Company
#
Liability Losses
#
Physical Damage
Losses
#
Lienholder (LP) and Additional Insured (AI) Information
Unit NO
LP/AI
Name
Address
Cargo Losses
Regulatory Filings
Base State _____Type of Filing Required: ☐FMCSA ☐ Form E
Permit. Do you operate in Canada? ☐Y
☐N
Filing
Required
Motor Carrier
or Permit #
☐Form H ☐Oversize/Overweight ☐ City ☐ Hazardous
Applicants Name and Address exactly as it appears on each Filing
Underwriting Questions
☐ Y☐ N
Has any insurance company cancelled or non-renewed your insurance in the past 3 years?
☐Y ☐N
Have you operated under a different name in the past 5 years?
☐Y☐ N
Is this company a subsidiary of another entity or does this company own or operate any subsidiaries?
☐Y ☐N
Has your FHWA authority been suspended or revoked in the past 3 years?
☐Y☐ N
Do you act as a freight broker or freight forwarder?
☐Y ☐N
Do you allow trip leasing under your authority or do you trip lease under others authority?
☐Y ☐N
Do you hire sub-haulers under your authority?
☐Y ☐N
Do you ever haul any hazardous materials other than ORM-D Consumer Commodities?
☐Y ☐N
Are loaded trailers/containers left unattended for more than one hour?
☐Y☐ N
Do you haul refrigerated goods?
☐Y ☐N
Is all equipment operated including PPT types owned by the company included in this application?
☐Y ☐N
Are all drivers covered by Workers Compensation?
☐Y ☐N
Does applicant lend, lease or rent any equipment to others?
☐Y ☐N
Does your operation by contract or regulation require liability limits in excess of $1,000,000 CSL?
☐Y ☐N
Do you haul any waste or refuge?
☐Y ☐N
Do you require the Uniform Interchange Intermodal Endorsement?
☐Y☐ N
Have you declared bankruptcy or reorganized in the past 5 years?
☐Y☐ N
Do you lease or hire drivers from a driver leasing company?
Provide details for all questions answered yes:
Comments to Underwriting Questions or Special Notes and/or Requests
Sales Opportunity
Briefly describe the sales opportunity this applicant offers including any past coverage or service issues not currently being
met by the incumbent carrier.
State Fraud Warnings
NOTICE TO APPLICANTS: ANY PERSON WHO KNOWLINGLY AND WITH INTENT TO INJURE, DEFRAUD, OF DECEIVE ANY INSURANCE COMPANY FILES A
STATEMENT OF CLAIM CONTAINING ANY FALSE , INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
APPLICANT AGREEMENT AND SIGNATURES
THIS APPLICATION MAY NOT BE USED TO BIND COVERAGE. COMPLETION OF THIS APPLICATION BY A PROSPECTIVE INSURANCE BUYER IS FOR THE
PURPOSE OF TRANSMITTING INFORMATION ONLY. COVERAGE WILL COMMENCE ONLY UPON THE EFFECTIVE DATE OF A SEPARATE CONTRACT BINDING
INSURANCE COVERAGE I.E. POLICY OR OFFICIAL BINDER FORM ISSUED BY AN AGENT AUTHORIZED BY XXXXXXXXXXX INSURANCE COMPANY.
I AUTHORIZE XXXXXXXXXXX INSURANCE COMPANY AND/OR THE AGENT/BROKER TO OBTAIN A COPY OF MOTOR VEHICLE REPORTS FOR VERIFICATION
OF THE INSURANCE FOR WHICH I HAVE APPLIED AND RENEWAL THEREOF. I UNDERSTAND THAT IN OBTAINING A MOTOR VEHICLE REPORT A
CONSUMER REPORTING AGENCY MAY BE USED BY THE INSURER AND I AUTHORIZE SUCH USE.
I REPRESENT ALL DRIVERS UNDER THIS POLICY HAVE AUTHORIZED ME TO CONSENT ON THEIR BEHALF FOR THE INSURER TO OBTAIN MOTOR VEHICLE
REPORTS FOR UNDERWRITING.
I REPRESENT ALL INFORMATION IS THIS APPLICATION AND ANY ATTACHMENTS THERETO ARE TRUE AND AGREE A MISREPRESENTATION OF ANY OF
THE FACTS BY ME MAY 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.
PRINT NAME
TITLE
SIGNATURE OF APPLICANT _____________________________________
DATE ____________________
SIGNATURE OF AGENT __________________________________
DATE _____________________
AGENCY NAME
AGENT LICENSE #
PHONE #
__