Insurance Trucking Services Application

INSURANCE TRUCKING SERVICES APPLICATION

Application Date:    Desired Effective Date:

Applicant / Insured Information

Sole Proprietor    Partnership    Corporation    LLC    Other:

Phone:    Email:

Operations Information

Years in Business:    Number of Power Units (Tractors):    Number of Trailers:

Number of Drivers Employed:    Are drivers leased or independent contractors? Leased    Independent Contractors

Policy Details / Coverages Requested

Select coverages requested and indicate limit, deductible (if applicable), and requested premium estimate.

Commercial Auto Liability — Limit: $   Deductible: $   Estimated Premium: $

Auto Physical Damage — Limit: Actual Cash Value   Deductible: $   Estimated Premium: $

Cargo / Goods in Transit — Limit: $   Deductible: $   Estimated Premium: $

Bobtail Liability — Limit: $   Estimated Premium: $

Uninsured / Underinsured Motorist — Limit: $   Estimated Premium: $

Medical Payments — Limit: $   Estimated Premium: $

Desired Policy Term: From to

Loss History / Prior Insurance

Prior Policy Period: From to

Yes    No

Exclusions and Acknowledgements

The applicant acknowledges that the policy, if issued, will contain standard exclusions including but not limited to intentional acts, punitive damages where prohibited by law, nuclear hazard, war, wear and tear, and loss arising out of illegal conveyance. Applicant must confirm awareness and acceptance of these exclusions.

Applicant acknowledges review of standard exclusions and understands coverage limitations.

Applicant consents to inspection of records, equipment and premises by the insurer or its representatives and authorizes release of driving records and loss history for underwriting purposes.

Applicant authorizes inspection and release of records for underwriting and claims investigation.

Beneficiary Designation (If Applicable)

Beneficiary Name:    Relationship:    Percentage: %

Additional Beneficiary (if any):    Percentage: %

The undersigned warrants that total beneficiary percentages equal 100% for all named beneficiaries. Any percentage that does not total 100% may invalidate beneficiary distribution.

Declarations and Certification

By signing this application, the applicant certifies that the statements and particulars contained herein are true, complete and correctly recorded to the best of applicant's knowledge. The applicant understands that any material misrepresentation, omission or incorrect statement may be grounds for denial of coverage, rescission of policy, or denial of claims. The applicant acknowledges that this application, including any attachments, shall form the basis of any policy issued.

The applicant authorizes insurers, their agents and representatives to make any investigation necessary, including inquiries of prior insurers, employers, and motor vehicle records. The applicant further authorizes release of loss runs and claim information to underwriters.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and subject to penalties under applicable law.

Applicant Attestation

I hereby declare that I am authorized to complete this application on behalf of the applicant named above. I attest under penalty of perjury that the information provided in this application is true and correct. I agree that this application shall be the basis for issuance of the policy and may be incorporated by reference in any policy issued.

I agree to the attestation and declarations contained in this application.

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