Get documents about "Hazardous Transporters Auto Liability _ Physical Damage Application
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Document Sample
Application Sponsored by…
Anchor Bay Insurance Managers, Inc.
Post Office Box # 2510 / Silverdale, WA. 98383
Phone: 800.929.9560 / Fax: 800.929.9794
Web Site: SurplusLines.com
Submit Applications To: Applications@SurplusLines.com
Hazardous Transporters Auto Liability & Physical Damage Application
Please include ACORD Cargo, CGL, Garage and Property Sections if those coverages are required.
Please include a Fixed Site Pollution App or Contractors Pollution App (as appropriate) as Pollution coverage is also required.
Do not use this application when Auto coverages are not required. Instead, use a Transportation Pollution Supplemental App.
Instructions
Please include the following 1. Financials 3. List of all Treatment, Storage and Disposal
with this application: 2. Currently valued loss runs (TSD) Facilities used by the applicant and
their respective permit numbers
Agency Information
Name:
Address: City: State: Zip:
Phone: Fax: Website:
Producer Name: Phone: E-Mail:
Assistant Name: Phone: E-Mail:
Applicant Information New Business Renewal
Business Name: Federal Tax ID#:
Legal Name: EPA ID#:
Type of Entity: Sole Partnership Joint Venture Corporation LLC Other
Mailing Address: City: State: Zip:
Physical Address: City: State: Zip:
Phone: Fax: Website:
Owner or Manager: Phone: E-Mail:
Pollution Risk Manager: Phone: E-Mail:
Accounting Contact: Phone: E-Mail:
Inspection Contact: Phone: E-Mail:
Date Applicant was established: Years at this location?
Coverage Information
Effective Date: Proposed Expiration Date: Need by Date:
For which of the following coverages is the Applicant applying?
Auto Liability Auto Trailer Interchange Garage Liability* Property*
Auto Physical Damage Cargo* General Liability* Pollution Liability**
* Please include ACORD Coverage Section with this app… **Please include Pollution Application with this app…
Application courtesy of… Insurance-Applications.com 1
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Coverage Information (continued)
Current Coverage
Coverage Current Limits Premium Retention
Auto Liability $ $ $
Auto Physical Damage $ $ $
Auto Trailer Interchange $ $ $
Cargo $ $ $
Garage Liability $ $ $
General Liability $ $ $
Property $ $ $
Pollution Liability $ $ $
Coverage Requested
Auto Symbols
Symbol 41 – Any Auto Symbol 47 – Hired Autos Only
Symbol 42 – Owned Autos Only Symbol 48 – Trailers in the applicant’s possession under a
Symbol 43 – Owned Commercial Autos Only Trailer Interchange Agreement
Symbol 44 – Owned Autos Subject to No-Fault Symbol 49 – Applicant’s Trailers in the possession of
Symbol 45 – Owned Autos Subject to Compulsory UM Law another trucker under a Trailer Interchange Agreement
Symbol 46 – Specifically Described Autos Symbol 50 – Non-Owned Autos Only
Auto Liability
Covered Auto Symbol Limits Deductible
Symbol 41 Symbol 46 Symbol ____ $1,000,000 CSL None
Symbol 42 Symbol 47 $ 500,000 CSL $_________
Symbol 43 Symbol 50 $_________ CSL
Auto Physical Damage AVC Stated Amount
Coverage Auto Symbol Limits
Comprehensive / OTC 42 43 46 47 $ _____________________
Specified Causes of Loss 42 43 46 47 $ _____________________
Collision 42 43 46 47 $ _____________________
Towing & Labor 46 $ _____________________
Hired / Borrowed Auto Liability
Non-Truckers States: Cost of Hire: $ ____________
Truckers If Any
None
Non-Owned Auto Liability
# of Employees: ______ States:
# of Volunteers: ______
# of Partners: ______
Hired Physical Damage
Primary Coverage States: # of Days_____
Secondary Coverage # of Vehicles_____
Application courtesy of… Insurance-Applications.com 2
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Coverage Information (continued)
Trailer Interchange
Coverage Symbol # of Trailers Farthest Zone # of Days Radius Deductible
Comprehensive / OTC 48 49
Specified Causes of Loss 48 49
Collision 48 49
Other Auto Coverages
Symbol 46 – Medical Payments Personal Injury Protection (PIP) Symbol 45 – Uninsured Motorist
Symbol 44 Symbol 46
Loss History
Currently Valued Loss Runs: Attached Requested Provide prior to binding Not available
Total claims, lawsuits and/or events or conditions or incidents in the past 5 years that may lead to a future claim or lawsuit:
Total paid and reserved for those claims (including defense): $ (Please attach loss runs or a complete description of all)
Please provide details of any claims paid or reserved, including defense, that exceed $5,000
Prior Carrier Information – Auto
Category 20__ 20__ 20__ 20__ 20__
Carrier
Policy Number
Premium
Effective Date
Expiration Date
Retroactive Date
General Information
Has any carrier ever declined, refused to renew or cancelled any insurance that had been issued to Applicant, a predecessor in
business, or to a person, firm, organization or joint venture managed by the General Manager, Managing Partner or Joint
Venturer or President named above? Yes No
If “Yes”, reason:
Non-Payment Agent no longer represents carrier Underwriting Reason (Describe the condition and what has
been done to alleviate the problem):
Gross Revenue: $________ For the upcoming policy year $________ For the 1st prior policy year
$________ For the current policy year $________ For the 2nd prior policy year
Application courtesy of… Insurance-Applications.com 3
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
General Information (continued)
Has Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy, judgment or lien during the last five (5)
years? Yes No If “Yes”, please provide the following:
Occurrence Explanation Resolution Resolution
Date Date
Operations, Exposures & Controls
Vehicle Summary
Company Owner/ Operation Tank
Power Equipment Number Cargo
Owned Operator Radius Capacity
Tractors
Heavy Trucks
Medium Trucks
Light / Service
Private Passenger
Tank Trucks (500
Gallons or less)
Tank Trucks (3,000
Gallons or less)
Tank Trailers (3,000
Gallons or less)
Tank Trucks (over
3,000 Gallons )
Tank Trailers (over
3,000 Gallons)
Van
Dump Truck
Refrigerated Trailers
Box Trailers
Garbage Trucks
Pickup Trucks
Stake & Flat Bed
Trucks
Vacuum Trucks
Flat Bed Trailers
Other (describe)
Other (describe)
Does the Applicant pull double trailers? Yes No Does the Applicant pull triple trailers? Yes No
Application courtesy of… Insurance-Applications.com 4
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Operations, Exposures & Controls (continued)
Cargo Transported (check all that apply)
Cargo % of Cargo Packaged % Drummed Bulk
Asbestos Containing Material
Contaminated Soil
Construction Materials / Debris
Demolition Debris
Explosives (ABC)
Fertilizer
Gasoline / Diesel
Grease
Hazardous Chemicals
Herbicides
Insecticides
Lab Chemicals
Lab Packs
Lead Containing Material
Manure
Medical Waste
Paint/Paint Thinners
Petroleum Products
Radioactive Meat
Recycled Material ﹘ Non Hazardous
Recycled Material ﹘ Hazardous
Other (describe)
Other (describe)
Does the applicant: Yes No
Operate any other business from any location that is not related to trucking?
If “Yes”, describe:
Enagage in any business other than trucking? Yes No
If “Yes”, describe:
Does Applicant haul or transport materials for others? Yes No
Does trip leasing comprise of more than 5% of gross receipts? Yes No
Are the number of units operated affected by seasonal operations? Yes No
Does the Applicant assume ownership of any product they haul? Yes No
If “Yes”, describe:
What is the driver population:
______ Full Time Employed ______ Owner Operator ______ Part Time Employed ______ Other(describe)
Application courtesy of… Insurance-Applications.com 5
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Operations, Exposures & Controls (continued)
Owners Operators
Are the owner operators exclusively hauling for the Applicant under written contract? Yes No
If “No”, explain:
Does the contract require non-trucking liability to be in place? Yes No
If “No”, explain:
Are owner-operators subject to the same hiring and training standards as company drivers? Yes No
If “No”, explain:
Are owner operators held to the same equipment maintenance standards as company equipment? Yes No
If “No”, explain:
Work Practices
Do all drivers have their CDL with the hazardous materials endorsement? Yes No
If “No”, explain;
Describe the driver selection process as follows:
Criminal Background Check Yes No
MVR Check Yes No
Reference Check Yes No
Road Test Yes No
Written Application Yes No
Who is responsible for screening drivers?
Is there a formalized program for all units? Yes No
Is the Applicant responsible for owner operator equipment? Yes No
Are vehicles equipped with theft alarms? Yes No
Are vehicles locked while unattended? Yes No
Are vehicles left loaded overnight? Yes No
Are passengers allowed in company insured vehicles? Yes No
If “Yes”:
Is management approval required and are liability release forms obtained? Yes No
Training and Safety
Is there a full time safety director? Yes No
If “Yes”, provide name, years of service and pertinent background information:
Do drivers receive training for tie-down and weight distribution procedures for flat bed operations? Yes No
How often are drivers safety meetings held?
Who holds the safety meetings?
Are all drivers required to attend? Yes No
Is there a record of attendance? Yes No
Application courtesy of… Insurance-Applications.com 6
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Operations, Exposures & Controls (continued)
Are the following programs and procedures formalized?
Safety Programs Yes No
Product Handling Procedures Yes No
Driver Hiring Procedures Yes No
Training Programs Yes No
Is there a written disciplinary program? Yes No
Are driver hiring criteria formalized? Yes No
Does the Applicant have a safety incentive program for drivers? If “Yes”, describe: Yes No
Vehicle Schedule
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
1
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
2
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
3
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
4
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
5
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
Application courtesy of… Insurance-Applications.com 7
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Vehicle Schedule (continued)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
# Year Vehicle Make Type of Vehicle Gross Vehicle Weight
Vehicle ID # Maximum Radius Garaging Location Cost New Zones (Near / Far)
Driver Information
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
Application courtesy of… Insurance-Applications.com 8
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Driver Information (continued)
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
# Employee or Name Date Date of Birth
Owner Operator Employed
State of Domicile License # Years Experience MVR Violations Last 3 Years Unit Driven
Loss Payee Information
# Name Address City ST Zip
2
3
4
5
Application courtesy of… Insurance-Applications.com 9
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Territory
Please indicate the percentage of units operating in each of the metropolitan areas designated below.
State State State State State
_____% Atlanta _____% Dallas _____% Little Rock _____% New Orleans _____% Richmond
_____% Baltimore _____% Denver _____% Los Angeles _____% New York City _____% St. Louis
_____% Boston _____% Detroit _____% Louisville _____% Oklahoma City _____% Salt Lake City
_____% Buffalo _____% Hartford _____% Memphis _____% Omaha _____% San Diego
_____% Charlotte _____% Houston _____% Miami _____% Phoenix _____% San Francisco
_____% Chicago _____% Indianapolis _____% Milwaukee _____% Philadelphia _____% Seattle
_____% Cincinnati _____% Jacksonville _____% Minneapolis _____% Pittsburgh _____% Tulsa
_____% Cleveland _____% Kansas City _____% Nashville _____% Portland, OR _____% Washington DC
Filings
Please indicate all states in which filings are required: (L = Liability; C = Cargo)
L or C State L or C State L or C State L or C State
Alabama Illinois Montana Puerto Rico
Alaska Indiana Nebraska Rhode Island
Arizona Iowa Nevada South Carolina
Arkansas Kansas New Hampshire South Dakota
California Kentucky New Jersey Tennessee
Colorado Louisiana New Mexico Texas
Connecticut Maine New York Utah
Delaware Maryland North Carolina Vermont
Dist. of Col. Massachusetts North Dakota Virginia
Florida Michigan Ohio Washington
Georgia Minnesota Oklahoma West Virginia
Hawai’i Mississippi Oregon Wisconsin
Idaho Missouri Pennsylvania Wyoming
Additional Insureds
Name: ______________________________________________ Name: ______________________________________________
Address: ____________________________________________ Address: ____________________________________________
City, State, Zip: ______________________________________ City, State, Zip: ______________________________________
Insurable Interest:: Lender Landlord Public Entity Insurable Interest:: Lender Landlord Public Entity
Other: ___________________________________________ Other: ___________________________________________
Loan / Permit #: _____________________________________ Loan / Permit #: _____________________________________
Application courtesy of… Insurance-Applications.com 10
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
Comments & Explanations (continued)
Warranty and Signature
As a condition precedent to coverage, the undersigned warrants that the information contained herein, including information
contained in any and all attachments, is true, complete and free of pertinent omissions and material misrepresentations, and
that he/she knows of no claims, lawsuits filed or pending, or events or conditions or incidents which may lead to a future claim
or lawsuit.
________________________________________ ________________________________________ __________________ ___/____/___
Applicant’s Signature Applicant’s Printed Name Applicant’s Title Date
Application courtesy of… Insurance-Applications.com 11
http://surpluslines.com/products/haz-trans-auto.pdf (01/10)
