1. Name:
2a. Address:
2b. E-mail Address:
3. Number of years in this business:
4. Usual radius of operations:
Less than 50 miles
50 - 100 miles
Greater than 100 miles
5. Percentage of operations into the USA:
6. Type of cargo usually carried:
7. Address of Principal Terminal:
8. Fire and Theft precautions at terminal:
9. Total Present Value of Schedule:
10. Limit any one single unit:
11. Limit any one combination:
12. Limit any one occurrence/terminal:
13. Details of driver hiring policies and investigations:
Please note Exclusion 5(1) of the Insuring
Conditions in the Policy excludes loss to any vehicle
while being operated by a driver under 23 years of
age. Underwriters may, at their discretion, cover
drivers under age 23 but this extension will only be
granted after Underwriter's specific agreement to do
so.
14. Will any of the scheduled equipment be loaned, leased
or rented to a third party?
Yes
No
If yes, please provide details as to who is
responsible for loss to the equipment while in
possession of the third party:
15. Is the equipment inspected and serviced in accordance
with the manufacturers' specifications?
Yes
No
16. Please describe all losses in the last five years:
17. Have you ever had this type of Insurance cancelled or declined in the past?
Yes
No
If yes, please provide details:
18. What is the length of vehicle lease and financing being applied for?
19. For a quote on these additional coverages, check the appropriate boxes:
Collision Deductible Buy Down
Loss of Use
Personal Effects
DECLARATION & DISCLOSURE
This application shall not be binding on the Underwriters
unless and until a contract of insurance is issued and
delivered in accordance herewith and then only as the
commencement date of said insurance and in accordance with
all terms thereof. The Applicant hereby covenants and
agrees to and with the Underwriters that the foregoing
statements and answers fully and truly represent, to the
best of the Applicant's knowledge, all the facts and
circumstances with regard to the risk to be insured. The
Applicant also agrees that the answers and statements
contained herein form the basis and conditions of the
insurance.
The Applicant understands that the application can't be
signed.
