MOTOR TRUCK CARGO APPLICATION

Applicant’s Name:	Broker:	Broker Code:
Applicant’s Address:	How Long in Business:
Policy Period: to (12:01 AM)	Annual Revenue: $

Description of business:
Common Carrier:	Private/ Contract Carrier:
Is the applicant hauling own goods?	Goods of others?
Does the applicant use sub-contractors? Yes No
Are sub-contractors required to show proof of insurance? Yes No
Commodities hauled: USA: Radius:
Maximum value per load:	Average per load:
Is there a Bill of Landing, and with whom?
Have all drivers’ history and accident records been checked? Yes No
Limit required $	Deductible 5%/ 1000 min.
Type of coverage: All Risk Named Perils

List of powered units:
Year	Trade Name	Body	S/N

Loss and Policy History
Have there been any losses or claims by the applicant in the past 5 years? If yes, complete below: Yes, No
Date of Loss	Location #	Cause	Paid Amount	Insurance Company	Policy #
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Commercial Insurance in the past 5 years? Yes, No
Supporting Business: Policy #:	Company:

Applicant’s Signature:	Date: