Transportation Supplemental Application NE

Transportation Supplemental Application – NE

(to be used in addition to ACORD 132 and 194)

Name of Insured: ______Policy Effective Date: ______

Mailing Address: ______Years in Business: ______

______Agent: ______

DOT # ______ICC # ______Federal Employer ID #: ______

Major Clients:

______

Any oversized loads or Special Permits?YesNo

If yes, describe: ______

Radius of Operation(identify % of runs, or # of power units, which fit into the 4 categories – total to 100%)

______%0-50 milesLocal

______%51-200Intermediate/Long

______%201 – 500Long haul – A

______%Over 500Long haul – B

Owner Operators?YesNo

Are Trip Lease operators used?YesNoCost of Hire: ______

If yes, how many trip lease operators used? ______

How many trip lease operators one year ago? ______two years ago? ______

Are Permanent (Exclusive) Lease operators used?YesNo

Cost of Hire: ______

If any “Yes” responses, attach copy of your Contract(s) with owner operators.

Are Bob-tail insurance certificates obtained on all owner operators?YesNo

Minimum Limited required: $ ______

Do owner operators purchase Truckers Liability insurance or just Bobtail? ______

Do owner operators haul under their own operating rights or the Insured’s? ______

Are permanent lease operators’ vehicles included in vehicle schedule on application?YesNo

Do owner operators purchase their own physical damage coverage on their tractor?YesNo

Are owner operators complying with all DOT requirements?YesNo

Does insured keep complete driver files on all owner operators?YesNo

Safety Program:

Does the Insured have a Safety Program?YesNo

Formal:YesNo

Informal:YesNo

Date implemented:______

Explain any material changes in the Safety Program over the past 5 years, if any: ______

______

Any use of new technology to improve safety? (collision warning devices, satellite vehicle tracking, etc)

______

Full Time Safety Director?YesNo

If yes, name of Safety Director: ______

If no, name of person in charge of Safety, and title: ______

Formal Accident Review Procedure?YesNo

If yes, provide copy of procedure.

If no, how are repeaters identified?

______

Is Driver Check or a similar Vendor (1-800) used?YesNo

If yes, name of vendor: ______

How long has the Insured used this service? ______

Does the Insured have a policy banning radar detectors?YesNo

Other aspects of safety program worth noting:

______

______

Driver Management:Indicate which of the following procedures are used by Insured

Prior to Hiring:

Application for employment:YesNoPrevious Employer Checked:YesNo

Reference Checks:YesNoRoad Test:YesNo

Written Exam:YesNoPhysical Exam:YesNo

Pre-Hire Drug Test:YesNoPolygraph Test:YesNo

Minimum Age requirement ______Police Record Checked:YesNo

Any minimum experience requirement on same equipment? ______

MVRs obtained prior to hire?YesNo

After Hire:

Road PatrolsYesNo

Driver Files per DOT standards?YesNo

Motor Vehicle Records Obtained:YesNo

MVR Frequency after Hire:Annually twice per year quarterly other: ______

MVR criteria. Does the Insured have criteria for establishing an acceptable MVR? Yes No

If yes, please describe: ______

______

Is MVR criteria in writing?YesNoIs it communicated to all drivers?YesNo

Any Driver Incentive Programs (performance or Safety)?YesNo

If yes, describe: ______

Any Disciplinary Programs?YesNoIf yes, describe: ______

______

______

Are Disciplinary records kept on drivers?YesNo

Kept in Driver File?YesNo

Describe Drug Testing Program for employed drivers:

______

______

Describe what driver training is provided and frequency:

______

______

Driver Compensation:

How are drivers paid?

Hourly Salary: ______Revenue: ______Per Trip / Load: ______Per Mile: ______

Other: ______Please specify: ______

______

Vehicle Maintenance:

Preventative Maintenance Program?YesNo

Written?YesNo

Vehicle records kept?YesNo

Based on time or mileage? ______

Pre-trip inspections?YesNo

Post trip inspections?YesNo

In-house program?YesNo

Outside service?YesNo

If yes, are certs obtained?YesNo

Are owner operators required to participate?YesNo

Does Insured repair vehicles of others?YesNo

If yes, annual receipts? ______

Are retreads used?YesNo

If yes, how often? ______

If using open trailers, how are loads secured? ______

Personal Use of Vehicles:

Does the Insured restrict personal use of company vehicles?YesNo

If yes, how? ______

If yes, is the restriction in writing and provided to all drivers?YesNo

Are any vehicles taken home by employees?YesNo

Is there any personal use allowed of any Company vehicle?YesNo

If so, provide details (are children, spouse of employees also permitted to drive?) ______

______

______

Loss runs: Attach, the current year and the past 4 years, currently valued. Identify liability deductibles, if any. Also, the actual time period for the exposure base and the time period for each loss run need to match.