DUMP TRUCK TRANSPORTATION SUPPLEMENTAL APPLICATION by xkv18799

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									                                        DUMP TRUCK
                          TRANSPORTATION SUPPLEMENTAL APPLICATION

Section I - General Information

1. Insured Name __________________________________________________________________________________

2. Years operating this business ______________________________________________________________________

3. Years commercial experience operating a Dump Truck or Tractor with a Dump Trailer_________________________

Section II - Dump Operation (including Cement Truck)
Liability (Select one)

   Dump Not For Hire (risk owns the product that is hauled)

   Dump For Hire Single Concern (risk can be a fleet or a non-fleet and hauls 100% of the time for one Concern)

  Name of Concern _________________________________________________________________________________

   Dump For Hire Multiple Concerns (risk can be a fleet or non-fleet and hauls for 2 or more Concerns)

Physical Damage
Body/Structure type:     End Dump*         Side Dump**         Belly Dump

* If unsure of body type, select End Dump.
** Concrete and Cement trucks should be classified as Side Dump.

Types of Cargo hauled:      Sand       Gravel      Dirt       Asphalt

Largest City operated in_______________________________________________________________________________

Garaging City _______________________________________________________________________________________



____________________________________________________                    _______________________________________
Applicant                                                                 Date




00-AU 1137                                      Page 1 of 1                                                       6-03

								
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