% of Hauls by Distance - Must Equal 100%

MOTOR TRUCK CARGO

Applicant

Country ofApplicant: / Currency:
DBA Name ofApplicant:
Address:
Country:
City: / Prov: / Postal:
YearEstablished: / FilingsRequired: / Yes No / FHWA DocketNo.
Type ofCarrier:

% Of hauls by distance - Must equal 100%

1 – 250Miles / 251-1000Miles / 1001 +Miles / Number of tripstoAlaska peryear
LongTerm Contract Operators / ShortTermorTripLeases

% Of loads not hauled by your owned trucks

(NB: Long Term = 30 Days +)

Number & Type of Power Units requiring MTC Cover Number & Type of Trailers

OwnedByYou / ContractOps
PickUps
LightVans
StraightTrucks
Tractors
Other
TotalPower Units
OwnedByYou / ContractOps
Flatbeds
ContainerFlats
ClosedTrailers
TankTrailers
ReeferTrailers (<10years)
ReeferTrailers (>10years)
CarCarriers
B-Trains/Trailersin Tandem
Other
TotalTrailers
GrossReceipts / Owned Trucks$ / Contract Ops$ / Brokered$ / Total$
Est. for next 12months
Prior 1Year
Prior 2Years
Prior 3Years
Prior 4Years
Drivers Age Profile / Your Drivers / Your Drivers / Confirmwhenhiringnewdriversoroperators youmakethefollowingchecks:
23 - 24
25 –65 / MotorVehicleRecord? / Yes / No
Over 65 / ReferencefromPrevious Employer / Yes / No
Total Drivers

Target hauled commodities

Please note that the cargoes shown on this page are normally excluded from coverage by the policy wording. To request coverage for these cargoes, you must complete the fields for each commodity.

Please complete the grid below for all commodities you expect to haul:

TYPE OFCARGO / % Ofhauls / Avg. value$ / Max Value$
Alcohol
Bullion, Fine Arts,etc.
Documents
Electronics
Garments
HouseholdRemovals
LiveAnimals
Seafood
Tobacco
Total / %

Hauled commodities – Non target

Type ofCargo / % OfHauls / Avg. Value$ / Max Value$
Air conditioningequipment
Animalfeed
Autos – not OnHook
Bakeryproducts
Beverages (NonAlcoholic)
Boats
Books
Boxed manufactureditems
BuildingMaterials
Candy
Cannedgoods
Carpet
Cloth
Cotton
Drygroceries
Electrical equipment (notelectronics)
Fertilizers
Gasoline (inbulk)
Grain
Gravel
Hardware
Hay
HeavyMachinery
Logs
Type ofCargo / % OfHauls / Avg. Value$ / Max Value$
Lumber
Meat
Milk in bulk (notreefer)
Mobile Homes (inclD/Wides)
Mobile Homes (notD/Wides)
Newfurniture
Oil (inbulk).
Oilfieldequipment
On hook – for autos /trucks
Paint
Paper(boxed)
Paper in rolls or onspools
Pipe
Plants (notreefer)
Plastics
Produce (notreefer)
RecreationalVehicles
Refrigerated Loads (notseafood)
Rubber
Sand
Seed
Soap, householdcleansers
Steel
Tires
Tobacco(raw)
Trailers – on ownwheels
Trailers (onflatbeds)
WoodChips
Please type in below any cargoes not included above. Be as specific aspossible.
Total non targetcommodities / %
Total targetcommodities / %
GrandTotal / % (Must equal100%)

Limits & coverages

Anticipated Inception Date:

Cover Required: Broad Form 15

What policy limits do you require? / Note below any special exceptions or reasons for especially high limits: There is more space at the end of the form if you need
TruckLimit / $
LossLimit / $
Deductible / $

Note below any special reasons for a variable deductible. Underwriters usually impose a deductible of at least $5000 for theft oftargetitems (items A to H on previouspage).

Optional endorsement requested

Please indicate which optional endorsements you would like to purchase and specify limit.

ENDORSEMENT / LIMIT$
1 / Cargo on Trailers in Tandem Endorsement – Please advise what percentage oftheoperation uses trailers intandem:% / Yes No
2 / Refrigerated Breakdown Endorsement. Min Deductible$2500.00NOTE: Ten year age limitation in thisendorsement. / $
3 / RiggersEndorsement. / $
4 / Contingent Transit Endorsement (TruckBrokering). / $
5 / Unattended TruckEndorsement. / $
6 / Earned FreightEndorsement / Yes No
7 / Debris RemovalEndorsement / $
8 / L.T.L. Endorsement (Off TruckCover) / $
CoverforcargoUNLOADEDfromtrucksisrequiredatthefollowingterminals / $
Address / Limit$
A / $
B / $
TerminalProtections: / Fully Fenced /Gates / 24 HourGuards / BuildingAlarmed / BuildingSprinklers
A
B
9 / In Full PremiumEndorsement
Limits cover to named trucks only. We will need a list of VINnumbers. / $
10 / Trailer InterchangeEndorsement
Approx no. of trailer interchange day’s perannum? $ / Any onetrailer. / $
Any oneloss. / $
11 / Target InterestInclusionEndorsement / Target goods to becovered / Deductible / $
$

Note: All Policies are subject to a 25% minimum retained premium.

Loss information

Please complete, whether the loss was insured or not.

Year / Deductible$ / Amount Paid$ / Amount Pending$ / Describe MajorLosses
PriorYear
Prior 2Year
Prior 3Years
Prior 4Years
Prior 5Years
CurrentInsurer: / Policy ExpiryDate:
dd/mm/yyyy
CurrentPremium: / $ / CurrentDeductible: / $
Hasanyinsurerwithinthepast5yearsrefusedtorenew,orcancelledyourpolicy? Yes No

Additional information

Please show below or in a separate document any other material facts.

VehicleInformation
VehicleDescription / SerialNumbers
DriverInformation
Name / Date ofBirth / Drivers LicenseNumber

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 contract, 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. I/we agree that if the proposal or any part of it has been completed by another party, that I/we have studied the information herein and have made any necessary amendments to such information. I/We have been advised by the broker and consent to any information that may be perceived as personal information for collection, appropriate use, and disclosure of to third parties (PIPEDA).

Date: Signed:

Position:

BROKER INFORMATION:

Broker Name: Contact Name:

Address: City: Prov: Postal:

Phone: FAX:

#100 1400 1st Street SW
Calgary, AB T2R 0V8
Tel.: 1-855-745-1010
Fax: (403) 237-9976
/ 4405, boulevard Lapinière (head office)
Brossard, QC J4Z 3T5
Tel.: 1-855-745-1010
Fax: (450) 672-5533 / 2550, boulevard Daniel-Johnson, #420
Laval, Québec H7T 2L1
Tel.: 1-855-745-1010
Fax: 450-681-7313
/ 235 Yorkland Blvd., Suite 1100
Toronto, Ontario M2J 4Y8
Tel.: 1-855-745-1010
Fax: (416) 925-7260
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