Policies Will Not Be Issued Without SSN/FEIN

Fleet
Transportation
Application / / In Pennsylvania & West Virginia:
2307 Menoher Blvd., Johnstown PA 15905
(800)452-0297 FAX (814)255-6010
In Maryland:
111 Warren Road, Suite 1B
Cockeysville, MD 21030
(800) 759-7779 FAX (814) 628-6914

Policies Will Not Be Issued Without SSN/FEIN#

This application can be processed without delay if the following documents are provided:
A. Currently valued insurance Company

A completed equipment schedule showing vehicle type, make, model and values.
A copy of current MVR’s for all drivers on all new business.

D. Schedule B fuel tax report for last year. / New
Renewal / Coverages Desired:
Auto Liability
Physical Damage
Cargo
1. Name: / 2. Physical Address:
3. Mailing Address:
4. Social Security Number or Federal Tax ID Number: / 5. Business Phone Number:
6. Date Coverage Desired: /

Who should we contact for a loss control inspection?:

Phone Number:

9. Applicant is: Corporation Partnership Joint Venture Individual Other:

How many years does applicant have with truck insurance in own name as owner of business?

11. Loss Experience / Provide the following insurance information for the past three years or submission will not be processed.
Has any Insurance company cancelled or non-renewed your policy in the past three years? Yes No
Is current Carrier non-renewing? Yes No
If yes, explain:
Prior 3 Yrs / Insurance Company / Policy Number / Coverage / Prior 3 Yrs Amount & Number of Liability Losses / Prior 3 Yrs Amount & Number of Phys. Damage Losses / Driver(s) Involved in Loss(es)

Operations

a. Commodities Hauled:
b. Gross Revenue: Last 3 Years: -$ -$ -$
c. Mileage: Last 3 Years: - - -
d. # of Units Operated: Last 3 Years: - - -
e. Prior Fleet Values: Last 3 Years: -$ -$ -$
f. Estimates for next policy year: Revenue: $ Miles:
g. Do you pull any Double Trailers? Yes No If Yes, What Percentage? %
h. You are a: Common Carrier Contract Carrier
i. Do you pull any Triple Trailers? Yes No If Yes, What Percentage? %

Is all commercial equipment you own or operate described in the application? Yes No

If No, Explain:
k. Radius of Operations: 0 to 100 miles% 101 to 300 miles% 301 to 500 miles % Over 500 Miles%
i. Check cities served by showing % of overall operations to each: / Miami / Portland
Atlanta / Cincinnati / Houston / N.Y.City / Richmond
Balt.-Wash. / Cleveland / Indianapolis / Oklahoma
City / St. Louis
Boston / Dallas/
Ft.Worth / Jacksonville / Omaha / Salt Lake
City
Buffalo / Denver / Kansas City / Phoenix / San
Francisco
Charlotte / Detroit / Little Rock / Philadelphia
Chicago / Hartford / Los Angeles / Pittsburgh / Tulsa
13. Driver Information / Must be completed for all drivers or submission will NOT be processed. / Information for additional drivers should be attached.
Current Number of Drivers: Turnover in the last 12 mos.: Replaced: Added:
Driver / Date of Birth / License Numbers / # Yrs. Employed by you / # Yrs. Comm’l Driving Exp. / # Accidents / In Last 3 Years # Violations / License Suspended/ Revoked
14. Driver’s pay is calculated by: Trip Hourly Other (explain):

Driver’s maximum hours: a. Driving daily, weekly

b. On duty daily, weekly
16. Equipment (List number of owned or leased units of each type)
Classification / Trucks / Tractors / Semi-Trailers / Other:
Company Owned or Leased
Long Term Lease With Drivers
Totals

Please complete the schedule of vehicles on pages 5 and 6.

18. Does Motor Carrier Act apply to you?
No, why not?
Yes, please attach the MCS-90 Endorsement to my policy as:
Type 1 Nonhazardous Commodities Type 2 Hazardous Commodities
Type 3 Hazardous Commodities
Leasing/Brokerage/Trailer Interchange: Provide copies of lease or agreements
19. Do you trip lease to other carriers? Yes No If Yes, list carriers:
20. Revenue when trip leased past 12 months: Estimate next 12 months:
21. Do other carriers trip lease to you? Yes No
22. Revenue paid to hired trucks last 12 months: Estimate next 12 months:

Are you full-tim leased? Yes No if Yes, to whom?

Are you responsible for Primary Insurance Coverage? Yes No

Do you operate as a freight broker, freight forwarder or arrange loads for others? Yes No

If Yes, provide brokerage name and docket number:
Annual Brokerage Revenue: $ What % of your operation is brokerage? %
Trailer Interchange: Do you use non-owned trailers? Yes No How many per week? Per year?

Maximum value Average value

Are you responsible for Physical Damage? Yes No
27. Written Agreement Other Provide copies of written agreements

Motor Truck Cargo

Cargo Insurance Requested: Amount $

Deductible $ / Commodity Transported / % of Total Revenue / Value Per Truck Load
Maximum / Average

Current Carrier:

Current Rate:
30. Terminal Locations / Limits of Liability / Avg. Value at Terminal / Construction / Protection (*)

(*)Protection – i.e., fenced, guards, open 24 hours, etc.

Maintenance Information

31. Do you have a written maintenance program? Yes No If Yes, attach a copy.

Do you service your own vehicles? Yes No

If Yes, How many mechanics do you employ? If No, who does?

Does vehicle maintenance program include the following:

A service record of each vehicle? Yes No
Controlled Inspection frequency? Yes No
Vehicle daily conditions reports (attach copies)? Yes No
The above for leased vehicles Yes No

34. How often are these various reports reviewed by management?

Safety Information

Attach copies of latest DOT or applicable state authority inspection reports, if such inspections are made. Answer ALL questions or submission will NOT be processed.
35. Do your Driver selection procedures include:
A. Written Applications? / Yes No
B. Reference Checks? / Yes No
C. Written Test? / Yes No / Certificates? Yes No
D. Road Test? / Yes No / Certificates? Yes No

E. Physical Exams:
(1) Pre-Employment?

(2) Federal DOT Requirements?
(3) State DOT Requirements?
(4) Periodically during employment? / Yes No
Yes No
Yes No
Yes No / If No, please specify how often:
F. Review MVR before hiring or leasing Driver? / Yes No

Updating MVR records periodically during employment?

/ Yes No / Specify how often:
H. Drug Testing? / Yes No / During Employment?
Yes No

Does Driver indoctrination

include:
A. Company rules and policies? / Yes No /

Route Familiarization?

Yes No

Daily DOT vehicle inspection procedures?

/ Yes No /

Emergency procedures?

Yes No
C. Equipment familiarization? / Yes No /

Accident reporting

procedures? Yes No

Does road supervision include:

Mechanical recording devices?

/ Yes No /

Radio Dispatch?

Yes No
B. Computer/satellite tracking? / Yes No

Are accident investigation and review procedures, including records, maintained? Yes No

Does the revies procedures include disciplinary procedures?Yes No
If Yes, explain

Is it the policy of the applicant trucker to allow passengers to ride

in the truck – tractor with the drivers? / Yes No
Insured Agreement

Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer submits an application or files a claim containing false or deceptive statements is guilty of insurance fraud.

This applicant agrees to furnish promptly the 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 payments 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 changed 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 Interstate Commerce Commission, or both, it is agreed as between the company and the undersigned that all the provisions and agreements of the policy shall be in full force and effect 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 in said policy, and if the Company shall be obliged to pay any claim that it would not be obliged to pay if said endorsement 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 is not an appointed agent of the Insurer and does not have authority to bind coverage.

Coverage will be effective only when bound by the General Agency in writing.

General Agent:
Interstate Insurance Management, Inc.
2307 Menoher Boulevard
Johnstown, PA 15904 / Applicant for Insurance Title
Signed at (City) (State)
Date

IMPORTANT: Prompt Reporting of Accidents is Required.

Request for Filings
Please : Make Amend* Cancel** Reinstate Refile Renew
*Reason for Amend: / **Reason for Cancel:
Do you have ICC authority? Yes No / If Yes, Docket Number:
Do you have Brokerage authority? Yes No / If Yes, under what name & Docket Number:
Insurance Carrier:

Name & Address Information for Filings

State / Docket or Permit / Applicant’s Name & Address as it Appears on Each Permit

L = Liability C = Cargo

L C / L C
Alabama / New Mexico – Docket # ($15 fee)
Payable to: New Mexico State
Corp. Comm.
Arizona / New York – Intra State Only
Arkansas / North Carolina
California - ICC Exempt Only
-EX #
-Intra State Only / North Dakota– Intra State Only
Colorado / Ohio
Connecticut / Oklahoma ($15 fee) O.C.C. #
Payable to: Oklahoma Corp.
Comm.
Florida / Oregon
Georgia FEI# / Pennsylvania – Intra State Only
Idaho – Intra State Only / Rhode Island – Intra State Only
Illinois – ($25 fee)
Payable to Illinois Commerce
Commission / South Carolina
Indiana – PSCI# / South Dakota
Iowa / Tennessee
Kansas / Texas ($100 fee – Form E only)
Payable to: Texas Railroad
Commission
Kentucky – KYU# / Utah
Louisiana / Virginia – Intra State Only
Maine / Washington
Michigan – Intra State Only / West Virginia – WV Licensed Only
Minnesota / Wisconsin
Mississippi / Wyoming – Intra State Only
Missouri / ICC (Cargo Common Carrier Only)
Montana – Intra State Only
Nebraska
Nevada – Intra State Only
Oversize/Overnight Liability:
Canadian Province(s):

Coverage Information

Applicant Name:
Liability Coverages / Physical Damage Coverages
Truckers Liability $CSL / Specified Perils, Deductible $
Non-Truckers Liability $CSL / Collision, Deductible $
Medical Payments $ / Trailer Interchange, Limit $
Symbol #48Symbol #49
*Uninsured Motorist $
*Underinsured Motorist $ / Rental Reimbursement Limit $per
10 Day20 Day30 Day
*Personal Injury Protection $
Hired Auto / * Complete and Attach Selector Forms
Non-Owned Auto No.
Cargo (See Application)
Pollution
Lessee Coverage: 10% 20%
30% of operations

Vehicle Schedule

Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:
Veh. # / Year / Make, Model, Body Type / Zone / Terr. / Misc. Type / VIN/Serial Number
Zip Where Garaged: / Stated Amount / Radius / GVW/GCW / Loss Payee Name:

Vehicle Schedule - Continued

Page 1 of 6