Cargo and Physical Damage

Agent Information

Agency Name

-OR-

Agent Lookup Code

Agent Names

Agent Name (first and last)

Phone:

Fax:

Agent Email:

Agency's Mailing Address

Agency City

Agency State

Agency Zip

Insured Information

Insured Name

Insured Email

Insured Website

Insured Phone

Insured's Mailing Address

Suite, Unit, Floor, etc. (Optional)

Insured's Mailing City

Insured's Mailing State

Insured Zipcode

Year Established:

If year established cannot be filled or does not apply please leave blank.

MC Insured ICC Docket Number:

Are filings required?

Does this quote include all owned/operated units?

Type of Company/Carrier:

Does the insured also carry their own goods?

Please describe Carrier details:

Is Primary Garaging Address the same as the Insured's Address? (Click if Yes)

Primary Garaging Address:

Suite, Unit, Floor, etc. (Optional)

Primary Garaging City:

Primary Garaging State:

Garaging Zip

Does insured have any other Garaging Addresses?

Alternate Garaging Address

Garaging Address

Suite, Unit, Floor, etc. (Optional)

Garaging City

Garaging State:

Garaging Zip Code

Has insurance coverage for this applicant ever been placed through Commonwealth Underwriters? (Click if Yes)

Has this applicant ever operated under a different name? (Click if Yes)

Please give details of any operations carried out other than that of a carrier:

If no other operations are performed please fill in "N/A".

Does insured subcontract to other parties?

For physical damage quotes only, select "No".

Is subcontracting for long term (30+ days) leases or other basis?

Please describe subcontracting lease basis:

Are subcontractors responsible and insured for loss or damage to cargo?

Does insured maintain copies of sunbcontractor current insurance arrangements on file?

Prior Carrier

Has the insured had coverage in the last 3 years?

Has any insurer within the past 3 years refused to renew or canceled insurance on the applicant?

Is prior cargo coverage information known? (Click if Yes)

Has the insured had consecutive coverage for all lines being quoted for the last 12 months?

Please give details:

Prior Carrier Name:

Prior Perils Form:

Policy Premium:

Policy Deductible:

Policy Limit:

Policy Expiration Date:

Was a renewal offer made? (Click if Yes)

Is the owner also listed as a driver?

This will decline this quote. However, if you complete the rest of the form and submit it, it will be reviewed by an underwriter.

How many years of experience does the applicant have in the same type of work and/or exposure being submitted?

Is the prior employment information known?

Employer 1

Employer Name:

Employer Phone Number:

Employer Address:

Suite, Unit, Floor, etc. (Optional)

Employer City:

Employer State:

Employer Zip:

Starting Date of Employment:

Ending Date of Employment:

Unit Type:

Commodities:

Radius

Do you object to verification of the above information?

Quote Type

What type of Quote would you like?

Owner 1

Owner Name:

Drivers

Please detail the steps taken in employing new drivers.

What are the grounds for firing a driver?

Driver 1

Driver Name:

Date of Birth:

License Number:

License State:

Years Experience:

Date of Hiring:

Relationship:

Violation History Known? (Click if Yes)

Number of minor violations

Minor Violations:
-Speeding up to 19mph Over Legal Limit
-Failure to Stop
-Failure to Yield
-Improper Lane
-Disobeying Traffic Control Device
-Following Too Closely
-Wrong Way on a One-Way
-Improper Turn
-Improper Backing
-Illegal Passing

Number of major violations

Major Violations:
-Driving While License is Suspended or Revoked
-Illegal Passing
-Speeding more than 19mph Over Legal Limit
-Reckless Driving/Careless Driving/Improper Driving
-Eluding a Police Officer
-Open Containers
-Hit and Run
-Falling Asleep at the Wheel
-Speed Contest (Racing)
-Negligent Driving
-DUI, DWI, OUI, OWI

Number of at-fault accidents:

Power Unit 1

Year:

Make:

Unit Type:

Is the VIN number for the unit known?

VIN:

Trailers

Are there any trailers to schedule?

Trailer 1

Is the trailer owned by the insured?

Trailer Type:

Year:

Make:

Is the VIN number for the trailer known?

VIN:

Other Equipment Qualifiers

Does insured own or use equipment other than those listed above?

Are vehicles rented each time there is a job?

Does insured lease, loan, or rent any of the equipment to others?

Are all vehicles titled under named insured?

At what intervals?

Do any units have a Gross Vehicle Weight greater than 26,000 lbs (Click if Yes)

Do any drivers have less than 2 years with a Commercial Driver's License Class A (CDL-A)?

Please detail any steps taken to secure vehicles.

Physical Damage Loss Payees

Are there any Loss Payees?

Physical Damage Loss Payee 1

Loss Payee Name:

Loss Payee Address

Suite, Unit, Floor, etc. (Optional)

Loss Payee City

Loss Payee State:

Loss Payee Zip Code

Does this Loss Payee apply to all Units?

Risk Qualifications

Does applicant require terminal coverage?

Terminal Coverage is required if any vehicle will be parked in any one location for more than 72 hours and up to 30 days.

Does applicant require trailer interchange coverage?

Cargo Limit per Unit:

Average Exposure per Unit:

Maximum Exposure per Unit:

Limits of Insurance up to $100,000 for any one scheduled vehicle; or $200,000 for any one disaster (if more than one vehicle scheduled). For Higher limits, please contact your underwriter.

Does insured ever carry loads greater than the cargo insurance limit requested?

What is the Radius of Operations?

Cargo Deductible:

Default deductible is $1,000 for all classes, except $2,500 for refrigeration breakdown coverage and Household Goods movers.

Commodities

Does the cargo include liquor products or manufactured tobacco?

Does the cargo include any oversized or overweight commodities?

Does the cargo include any of the following commodities or types of operations? (Check if Yes)

Baled Cotton,
Chemicals,
Computers and Computer Components,
Copper and other precious metals and/or alloys,

Eggs,
Exotic Animals,
Explosives,
Fine Art,
Firearms,

Furs,
Gold/Silver,
Jewelry,
Money, Currency, and/or Coins,

Oriental Rugs,
Oversized and/or Overweight Cargo,
Pharmaceuticals,
Photographic Film,
Shellfish,

Please Select All Commodities Carried

Agricultural

Automotive

Building Materials

Consumer Goods

Food Products

Machinery Equipment

Miscellaneous

Total Percentage:

Refrigeration Breakdown

Does applicant require refrigeration breakdown coverage?

Are any trailers older than 10 years?

Is reefer trailer serviced at least once every 30 days?

Any seafood or shellfish hauling?

Districts of Operation

Please select all States and Provinces in which the Insured operates:

Gross Receipts

Please give gross receipts in respect of your trucking operation for past 4 years.

What is the estimated Gross Revenue for the coming year?

Applicant is considered a new venture and as such would not have Gross Reciepts for Prior Years.

Receipt Year

Year

Own Haul Total:

Subcontracted Total:

Losses

Have there been any losses in the last 3 years?

Please report all losses for the past 3 years

Loss 1

Loss Year:

Premium:

Losses Paid and Outstanding

Type

Loss Paid:

Loss Outstanding:

Please describe loss type:

Terrorism Coverage

Would contractor like Terrorism Coverage (TRIA)? (Click if Yes)

GL Information

Would the insured like GL coverage? (Click if Yes)

Please select a limit

Owner and office payroll (not including drivers and warehouse workers) ($):

Does the insured have a commercial auto liability policy in place?

If Yes, Limit:

Is any work subcontracted?

Cost of subcontractors:

Is there any warehousing of goods?

What is the warehouse payroll?

Are there any additional insureds? (Click if Yes)

Type of additional insureds:

Number of additional insureds:

Commission

What commission would you like for this account?

Additional Comments

Any Additional Comments:

Motor Truck Cargo And/Or Physical Damage Instant Quote

Agent Information

Insured Information

If year established cannot be filled or does not apply please leave blank.

Alternate Garaging Address

If no other operations are performed please fill in "N/A".

For physical damage quotes only, select "No".

Prior Carrier

This will decline this quote. However, if you complete the rest of the form and submit it, it will be reviewed by an underwriter.

Employer 1

Quote Type

Owner 1

Drivers

Driver 1

Power Unit 1

Trailers

Trailer 1

Other Equipment Qualifiers

Physical Damage Loss Payees

Physical Damage Loss Payee 1

Risk Qualifications

Terminal Coverage is required if any vehicle will be parked in any one location for more than 72 hours and up to 30 days.

Limits of Insurance up to $100,000 for any one scheduled vehicle; or $200,000 for any one disaster (if more than one vehicle scheduled). For Higher limits, please contact your underwriter.

Coverage is limited to the regular and frequent use within the radius selected.

Default deductible is $1,000 for all classes, except $2,500 for refrigeration breakdown coverage and Household Goods movers.

Commodities

Please Select All Commodities Carried

Agricultural

Automotive

Building Materials

Consumer Goods

Food Products

Machinery Equipment

Miscellaneous

Refrigeration Breakdown

Districts of Operation

Please select all States and Provinces in which the Insured operates:

Gross Receipts

Please give gross receipts in respect of your trucking operation for past 4 years.

Receipt Year

Losses

Please report all losses for the past 3 years

Loss 1

Losses Paid and Outstanding

Terrorism Coverage

GL Information

Commission

Additional Comments

Submission Failure