INTERSTATE
Insurance Mgt., Inc.
2307 Menoher Blvd.
Johnstown, PA 15905
Physical Damage / Cargo
Truckers Fleet Auto Application
1. Name / Phone NumberMailing Address
Garaging Location
Contact Name / FEIN Number / Date Business Started
Applicant is an Individual Partnership Corporation Joint Venture LLC Other
2. Type of Motor Carrier: Common Contract Broker Exempt Private
USDOT Number
Have you ever had a DOT compliance review? Yes No If yes, when?
Rating Assigned
Type of Carriage: Class 1 Non-Hazardous- $175,000 Class 2 Hazardous- $5,00,000
Class 3 Hazardous- $1,000,000
3. Date Coverage Desired From To New Renewal Rewrite
4. Coverages /
Limits of Liability
Bodily Injury Liability/Property Damage LiabilityHired Car Employer’s Non Ownership
Uninsured Underinsured Motorist Liability
Medical Payments Personal Injury Protection
Specified Causes of Loss Comprehensive
Collision Combined Deductible
Cargo Liability Combined Deductible
Other / $CSL
$CSL $
$Each Person
Stated Amount Per Schedule $DED.
Stated Amount Per Schedule $DED.
$Per Power Unit $DED.
$
5. Do you transport any anhydrous ammonia, explosives, gasoline, LPG, acids or chemicals?
Yes No If Yes explain below.
6. Type of cargo carried and percentage of each
7. Indicate Zones by showing percentage of long haul operations, over 200 miles to or from each city
group.
Zone 1 % / Zone 2 % / Zone 3 % / Zone 4 %
Balt. / Wash. / Atlanta / Hartford / Buffalo / Gulf Zone / Mnpls/St. Paul / Richmond / Remainder of the Country
Los Angels / Boston / Houston / Charlotte / Indianapolis / Nashville / St. Louis
Miami / Chicago / New Orleans / Cincinnati / Kansas City / Oklahoma City / Salt Lake City
New York City / Dallas /
Fort
Worth / Cleveland / Little Rock / Omaha / San Diego
Philadelphia / San
Francisco / Denver / Louisville / Pittsburgh / Seattle
Detroit / Memphis / Phoenix / Tulsa
Eastern Zone / Milwaukee / Portland
8. Radius of Operations: 0 to 50 miles% 51 to 200 miles%
201 to 500 miles% Over 500 miles%
9. Describe the five most common hauls you perform
10. Does the applicant ever allow any passengers other than company employees? Yes No
If yes, attach the applicant’s passenger program.
11. Does the applicant own or operate any equipment over 10,000 GVW other than listed in this
application or attachments? Yes No If yes, Explain
12. Do you pull double or twin trailers? Yes No If yes, percentage of loads Do you pull triple
trailers? Yes No
Applicant Name:
13. Is any Equipmenta. leased, rented or loaned to others? / Yes No
b. leased, rented or borrowed from others? / Yes No
c. interchanged with other carriers? / Yes No
Explain all Yes answers
14. Do you ever use subhaulers? Yes No If yes, how much did you pay to subhaulers in the last 12
months? $
15. Name of Present Insurance Carrier, Policy Number and Expiration Date:
16. Do you have your own Workers Compensation Policy or are you covered under any other Workers
Compensation Policy? Yes No
17. In the last three years has any insurance carrier canceled or refused to renew any coverages for which
application is being made? Yes No
Not Applicable In Missouri. If Yes, Explain
18. Loss Experience Summary MUST BE COMPLETED for at least the last three years; five years if over 25 power units. In addition currently valued loss runs for all years are required.
Insurance Carrier / From / To / Losses
Liability / Phys. Dam. / Cargo
No. / Amount / No. / Amount / No. / Amount
When loss runs are provided all losses not yet recorded on loss runs but of which the insured has knowledge are to be listed above.
19. Operations / No. of Units / Revenue / Mileage / Fleet ValuesNext Year
Current Year
Last Year
Year Before Last
If requesting a reporting policy, what basis for reporting? Revenue Mileage Units Values (For Physical Damage)
20. Does the applicant operate more than one terminal as shown in item 1? Yes No
If yes, complete the following for each terminal.
Location No. / O=Owned L=Leased / Address, City State, Zip
Loc. 2
Loc. 3Loc. 4
21. Attach Fleet Schedule of Vehicles – Private Passenger Types, SUV’s and Pickups with personal use are not permitted.
Equipment Summary
Classification / Trucks / Tractors / Semi-Trailers / OtherCompany Owned or Leased
Long Term Leased with Driver
Totals
Applicant Name:
22. Cargo Hauled / % / Maximum Value / Average ValueTerminal Coverage
Location Terminal Limit $Terminal & Yard Fenced? Yes No 24 hour supervision? Yes No Burglar Alarm? Yes No
a. Are all trailers/bodies locked at all times while loaded? Yes No
b. Is each unit equipped with a fire extinguisher? Yes No
c. Are loaded vehicles ever left unattended? Yes No
d. Are vehicles equipped with alarms? Yes No
e. Are drivers bonded? Yes No
f. Is a standard bill of lading used? Yes No
23. L or A / Unit Numbers / Full Name and Address of Loss Payee (L) or Additional Insureds (A)
24. Schedule of Drivers
Driver’s Full Name / State / License Number / Birth Date / EXP / VIO / ACC
25. Is the equipment inspected and maintained in accordance with USDOT requirements? Yes No
If no, explain
26. Are all drivers hired and monitored in accordance with USDOT regulations? Yes No
If no, explain
27. Have you had a USDOT compliance survey in the 3 years? Yes No
If yes, Date, Grading
Truckers Non-Fleet Application Rev 04/01/99
Truckers Fleet Auto Liability
Application
Vehicle Schedule
Applicant Name:
28. Schedule of Power UnitsPower Units – TT=Tractor ST=Straight Truck HT=Hot Shot TW=Tow Truck SV=Service Vehicle
Deductible and Coverage Options for Power Units SCOL Comp. Coll.
Unit No. / Loc. No. / Year / Manufacturer / Type / GVW/CCW / VIN Number
Must Include Full 17 Digit VIN to Bind / Stated Amount
Does any of the above equipment have booms, hoists, loaders, spreaders or other similar special equipment attached? Yes No
GFTA – Vehicle Supplement Orig. 08 00INTERSTATE
Insurance Mgt., Inc.
2307 Menoher Blvd.
Johnstown, PA 15905
Truckers Fleet Auto Liability
Application
Vehicle Schedule
Applicant Name:
29. Schedule of TrailersTrailers – Body Types VN=Van RF=Reefer LV=Livestock TK=Tanker PN=Pneumatic CR=Auto FB=Flatbed
Deductible and Coverage Options for Trailers SCOL Comp. Coll.
Unit No. / Loc. No. / Year / Manufacturer / Type / GVW/CCW / VIN Number
Must Include Full 17 Digit VIN to Bind / Stated Amount
Does any of the above equipment have booms, hoists, loaders, spreaders or other similar special equipment attached? Yes No
GFTA – Vehicle Supplement Orig. 08 00Applicant Name:
30. States Requiring Intrastate or Exempt Filings Liability CargoAK / CO / IL / LA / MN / ND / NV / PA / TX / WI
AL / CT / IN / MA / MO / NE / NY / RI / UT / WV
AZ / FL / IA / MD / MS / NH / OH / SC / VA / WY
AR / GA / KS / ME / MT / NJ / OK / SD / VT / CAN
CA / ID / KY / MI / NC / NM / OR / TN / WA
CA EX# / AZ Acct# / IL ID#
Is a USDOT filing required? Yes No / Base State for Single State Insurance Registration
31. Fraud Agreement
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.
Notice to Colorado Applicants
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 policy holder or claimant for 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.Notice to Florida Applicants
Any person who knowingly and with the intent to injure, defraud or deceive any insurer files a Statement of Claim or an application containing False, Incomplete or misleading information is Guilty of a Third Degree Felony.Notice to New York Applicants
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any maternally 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.Notice to Kentucky Applicants
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any material false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.Notice to Ohio Applicants
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any material false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.32. Insured Agreements
This applicant agrees to promptly provide driver data for every driver engaged during the policy period. Applicant, Agent or Broker understand and agree that no flat cancellation will be allowed and either or both guarantee payment of earned premium to final termination date of policy or of any filing made by the company on behalf of the Applicant.
In consideration of the premium charged for the policy for which this application is made, and the Company attaching to said policy, either the endorsements required by any State Commission or United States Department of Transportation, or both, it is agreed as between the Company and the undersigned that all of the provisions and agreements of the policy shall be in full force and effect in the same manner as if the said endorsement had not been attached. The Named Insured further agrees that the said policy shall not and does not protect the Named Insured against claims for injury, damage or loss sustained by any person when not caused by a motor vehicle specified on said policy, and if the Company shall be obliged to pay any claim it would not be obliged to pay if said endorsements had not been attached, the insured agrees to reimburse the Company in the amount paid and all sums including costs and expenses which shall have been paid in connection with such claims.
I, the Applicant, understand the Insurance Producer assisting me with the placement of this insurance coverage does not have authority to bind coverage. Coverage will be effective only when bound by the Program Manager by telephone, in person, or facsimile.
I hereby declare the foregoing statements to be true to the best of my knowledge and belief. In compliance with Public Law 91-508, this is to inform you that in connection with your recent application for insurance, policy renewal (1) an “investigative consumer report” may be made as to your insurability including, depending on the type of insurance involved, information as to character, general reputation, personal characteristics, mode of living, financial conditions, (2) that such information will be obtained through (but not limited to) personal interviews with friends, neighbors and associates and (3) upon written request a complete and accurate disclosure of the nature and scope of the “investigative consumer report” will be provided.
Date Signed Signature of Applicant Title
X
Date Signed Signature of Producing Agent Signed at
X
Producing Agency
Address City, State, Zip
Telephone Number FAX Number
GFTA Orig. 08 00 Page 1 of ___