Supplemental Application For Trucking
Please fill the form below
Section 1 — Applicant & Agency Information
Insured Name
Agency Name
Incumbent Agency?
Yes
No
Effective Date
Year Established
DOT #
MC #
FEIN #
Primary City of Ops
Main Garaging Address / City / State / Zip
Section 2 — Operations By Category
*
Business Category
*
Try: "Auto Haulers", "Freight Forwarders", "Livestock Hauling"...
Section 3 — Destinations
Destination 1 (City, State)
*
Destination 2 (City, State)
Destination 3 (City, State)
Destination 4 (City, State)
Destination 5 (City, State)
Section 4 — Commodities Hauled
Commodities Hauled 1
*
Commodities Hauled 2
Commodities Hauled 3
Commodities Hauled 4
Commodities Hauled 5
Section 5 — Miscellaneous Info
Any Filings Required? (specify)
Purchasing excess? If yes, limits desired
Do you rent or lease your trucks to others?
Yes
No
Do you broker/freight forward loads?
Yes
No
Are Trip lease operators used?
Yes
No
Do you allow Team Driving?
Yes
No
All drivers have 5 years US driving experience?
Yes
No
All drivers have 2 years CDL experience?
Yes
No
Do you transport any hazardous material?
Yes
No
If yes, please specify
Radius % of Operations (check all that apply)
0 – 50 Miles
51 – 100 Miles
101 – 300 Miles
301 – 500 Miles
501+ Miles
Total # of Drivers
# of Drivers Hired (last year)
# of Drivers Terminated (last year)
Driver Hiring Practices (check all that apply)
Written application
Pre-Hire Physical
MVR Interview
Reference Checks
Drug Testing
Driving Tests
Written Test
Criminal Background Check
Written MVR Criteria
Driver Training (check all that apply)
Route Familiarity
Equipment
Load Handling
Company Rules
Accident Reporting Procedures
Safety Devices (check all that apply)
Cameras
Accident Event Recorders (AERs)
Geographic Driving History Data
Mileage Tracking Device
Distracted Driving Warning System
Speed Warning System
Active Accident Avoidance Technology
Passive Accident Avoidance Technology
No Texting/Cell Phone Policy
1-800-HOWSMYDRIVING Program
If Yes, specify device/manufacturer
Do you pull double or triple trailers?
Yes
No
Oversize/Overweight loads?
Yes
No
Written safety program?
Yes
No
Cross border into Mexico or Canada?
Yes
No
Written maintenance program?
Yes
No
Vehicles used for personal use?
Yes
No
Driver incentive program?
Yes
No
Are service records kept for each vehicle?
Yes
No
Do you service your own units?
Yes
No
Allow others to operate under your authority?
Yes
No
Are all vehicles registered & licensed to the applicant?
Yes
No
Hire/use others' vehicles & drivers?
Yes
No
Driver selection program in place?
Yes
No
Driver monitoring program / disciplinary plan?
Yes
No
Monitor MVRs for all drivers?
Yes
No
Vehicle daily condition reports completed?
Yes
No
Pre/post trip inspections made regularly?
Yes
No
All equipment listed on vehicle schedule?
Yes
No
Section 6 — Cargo & General Liability
Cargo (check all that apply)
Cargo Contractually Required
Commodities stored overnight
Refrigerated Units
Had a cargo loss
General Liability (check all that apply)
GL Contractually Required
Any warehousing
Ops at storage lot or impound yard
Lease space to others
Operations other than trucking
Storage of goods/fuels/chemicals
Had a GL loss
I hereby declare that the statements made in this application and the contents of the other documents supplied are true and correct and agree that any policy of insurance that may be issued now or in the future will be based on warranties and representations contained therein.
*
Name
*
Title
*
Date
*
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