TRUCKER’S FLEET APPLICATION
TRUCK INSURANCE GROUP, LLC
102 Betsy Pack Drive, Jasper, TN 37347
(423) 942-1911 Phone / (423) 942-1988 Fax
Email to: info@trkinsgroup.com
Requested Effective Date:
GENERAL INFORMATION:
Exact Name and Address of Insured:
Garaging address if different:
Phone: ( ) Facsimile ( )
Person responsible for insurance:
Email Address:
Applicant is: Sole Proprietor Partnership Corporation
ICC Docket # MC USDOT# FEIN:
Is this how name appears on Auto Liability & Cargo Filings? Yes No
Conducting business in present form since:
OPERATIONS:
Description and Scope of Operations:
STATE FILINGS REQUIRED (INCLUDE FILING NUMBER)
What is your Base State:
CITIES ENTERED BY %:
Atlanta % Denver % Los Angeles % Okla. City %
Baltimore % Detroit % Louisville % Omaha %
Boston % Hartford % Memphis % Philadelphia %
Buffalo % Houston % Miami % Phoenix %
Chicago % Jacksonville % Nashville % Pittsburgh %
Cleveland % Kansas City % New Orleans % St. Louis %
Dallas % Little Rock % New York % San Fran %
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EQUIPMENT SUMMARY:
Extra Heavy Tractors Dry Van Trailers
Heavy Tractors Refrigerated Trailers
Heavy Trucks Flat Bed Trailers
Medium Trucks Dump Trailers
Light Service Trucks Tankers
Single Axle Dump Trucks Intermodal Chassis
Tri-Axle Dump Trucks Other
Do you own any equipment not scheduled on this application? Yes No
If Yes, explain:
All equipment operating under your authority scheduled on this application? Yes No
If No, explain:
For Primary Liability, is unhooked coverage to be provided for scheduled
Yes No
trailers?
If Yes, are trailers kept isolated from the public? Yes No
If Yes, are trailers fully enclosed by a fence? Yes No
DRIVER SUMMARY:
Local Drivers Long Haul Drivers
Local Owner/Operators Long Haul Owner/Operators
Minimum Qualifying Age – Company Drivers or Owner/Operators
Maximum Qualifying Age – Company Drivers or Owner/Operators
Are All Owner/Operators under permanent lease to the Named Insured? Yes No
Are All Company Drivers covered by Worker’s Compensation? Yes No
Do you use teams? Yes No
If Yes provide # of teams:
How many drivers were hired during the past 12 months?
How many drivers left your employ during the past 12 months?
What is the minimum years of CDL experience mandated by the company?
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CARGO DESCRIPTION:
The commodities hauled by the Insured principally consist of:
Commodity Max. Value Avg. Value % of Total
Apparel – Inner, Outer or Footwear
Appliances
Auto Part / Tires
Beverages – Beer, Wine or Spirits
Beverages – Soft Drinks or Water
Building Materials
Canned Goods
Computers / Parts / Peripherals
Dry Freight
Electronics – Small Consumer Variety
Electronics – Large Consumer Variety
Fish – Fresh or Frozen
Fragrances and Perfumes
Frozen Food
Housewares / Hardware
Iron / Steel / Metal
Juice or Juice Concentrate
Paper / Paper Products / Printing
Plastic / Plastic Products
Produce
Seafood – Fresh or Frozen
Tiles – Roofing, Flooring or Decorative
Tobacco or Tobacco Products
Other
Other
Other
Coverage for Target Commodities varies by insurance carrier and may be limited, restricted or otherwise
excluded under the policy form. Failure to specify Target Commodity exposures may result in exclusion of
coverage. Target Commodities shall mean all consumer and commercial goods, including but not limited
to; electrical appliances or instruments and any other audio/video-related equipment, Computers;
including all internal or external parts, chips, peripherals, monitors or other components, Wearing
Apparel, both innerwear or outerwear, including footwear, Seafood (fresh or frozen) including shellfish,
Perfumes and Fragrances, Alcohol, Tobacco and Tobacco related products.
Do you haul Hazardous Materials? Yes No
If Yes, explain:
Do any of your loads require placards? Yes No
If Yes, explain:
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Do any of your loads require temperature control? Yes No
If Yes, explain:
If Yes, are refrigeration units serviced regularly: Yes No
If Yes, are units serviced by a Certified Technician: Yes No
If Yes, are service records maintained: Yes No
Any Oversize/Overweight Operations? Yes No
If Yes, explain:
Any operations require specialty equipment or tarpaulins? Yes No
If Yes, explain:
Are Drivers engaged in Loading or Unloading operations? Yes No
If Yes, explain:
SECURITY PROTOCOLS:
Normal Hours of Operation: From: To:
Premises Supervised During These Times? Yes No
If No, When Supervised? From: To:
Is Security Provided After Hours? Yes No
Is Premises Lighted? Yes No
Is the premises Gated? Yes No
Are Any Trailers/Containers Left Loaded Overnight? Yes No
If Yes, State % of Loads Weekly:
EXPOSURE BASE - CURRENT AND PREVIOUS 3 YEARS
Period Gross Revenue Mileage Number of Units
Projected Exposures for Coming Policy Year
RADIUS OF OPERATIONS:
Radius Percentage Number of Power Units
> 50 Miles
50 to 200 Miles
201 to 500 Miles
10%, carrier may not provide a different Limit Per Conveyance for Specified Shippers.
SCHEDULED TERMINALS
Terminal #1 Limit
Terminal #2 Limit
Terminal #3 Limit
Terminal #4 Limit
Note: Coverage for Scheduled Terminals is subject to details of Security Protocols at each requested location
TRAILER / EQUIPMENT INTERCHANGE
Limit Per Conveyance
Deductible - Each Claim
Number of Days
Number of Units
Increased Limit for Specified Shipper(s)?
Yes No
If Yes, detail in section below
SPECIFIED SHIPPERS – INTERCHANGE COVERAGE
#1 - Name of Shipper Specified Limit
#2 - Name of Shipper Specified Limit
#3 - Name of Shipper Specified Limit
Has any company during the past 3 years, cancelled or non-renewed your insurance? Yes No
If Yes, explain:
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ADDITIONAL COMMENTS / LARGE LOSS DETAIL
APPLICANT WARRANTY
The applicant hereby applies to the company for a policy(s) of insurance as set forth in this application
on the basis of statements contained herein. Applicant agrees that such policy(s) shall be null and
void if such information is materially false or misleading so that the company would have rejected the
risk. Applicant understands that an inquiry may be made which will provide applicable information
concerning character, general reputation, financial stability and other pertinent financial data, or
other background information the company deems necessary in order to determine whether to accept
or reject the applicant for coverage. Upon written request, additional information as to the nature and
scope will be provided.
Signed this Day of 20
Signed at:
City & State
Signed by:
Authorized Representative of the Named Insured
Title:
Signed this Day of 20
Signed at:
City & State
Signed by:
Authorized Representative of Truck Insurance Group, LLC
Title:
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