Truckman Application dui phoenix arizona

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					Wellington F. Roemer Insurance, Inc.
3912 Sunforest Court
P.O. Box 8730
Toledo, Ohio 43623-0730
(419) 475-5151
Fax: (419) 475-8750



                            Truckman Application

Producer:                                                                    New
                                                                             Renewal


Quote Needed By:                                                Effective
                    ————————                                                  ————————


                                           Union/                              Year
First Named Insured:                       Non        Operations               Est


   P O Box
   Address
   City, St Zip

   Telephone
   Contact
   Safety Dir.


Corp:        Partnership:         Sole Proprietor:           Other:


Common Carrier:      ; Contract Carrier:    ; Exempt Hauler:     ; Private Carrier:

Public Truckmen:      ; Hauls Own Merchandise Exclusively:

                                     Union/                        Year
 Additional Named Insured(S):        Non    Operations             Est    Relationship




                                                         Presented by W. F. Roemer Insurance, Inc.
                                                                                       May, 2011
q Truckman Application

                         Table of Contents




    COVER                COMPANY & EXPIRATION

    PAGE          1.     OPERATING AUTHORITY & OFFICERS

                  2.     TERMINAL & BROKERAGE

                  3.     MILEAGE & RADIUS

                  4.     HAZARDOUS & CARGO EXPOSURE

                  5.     LEASED OR HIRED & CHANGES IN OPERATION

                  6.     EXHIBIT A / EQUIPMENT

                  7.     EXHIBIT B / FINANCIALS

                  8.     EXHIBIT C / EXPERIENCE & LOSS SUMMARY

                  10.    COMMODITIES / SHIPPERS

                  11.    FILINGS / MAJOR CITIES OPERATED IN

                  12.    SAFETY INFORMATION

                  14.    MAINTENANCE SUMMARY

                  15.    REQUESTED COVERAGES




                                             Presented by W. F. Roemer Insurance, Inc.
                                                                           May, 2011
q Truckman Application

Provide The Following Information For All Officers, Directors, Partners and
Stockholders of The Named Insured: *Must Total 100%
  Name                 Position/             Fulltime/   No. of Years    Pct
                       Function              Parttime    Years   Exp     Owner
                                                                             %
                                                                             %
                                                                             %
                                                                             %
                                                                             %
                                                                             %


Provide The Names of Any Trucking Entity Not Covered Under This Application In
Which The Insured or Any of Its Officers, Directors, Partners or Stockholders
Have A Direct or Indirect Interest:



Operations
    A - Description of Operating Authority
        Name And Address of Operating Carrier/ICC Docket #




    1)    Interstate Commerce Commission
    2)    Specific Intra State
    3)    Canadian Xtra/Intra            (Attach Copies of All Authority Held)


    B - Description of all Interline Agreements and/or all Trip Lease Agreements
        Involving Authority of Others Where A Hold Harmless Agreement Is
        Involved.




 Page 1                                                 Presented by W. F. Roemer Insurance, Inc.
                                                                                      May, 2011
q Truckman Application

C - List All Terminal Facilities Operated, whether Outbound or Backhaul, Owned or
    Leased or Commissioned Agent, and Show Percentage of Gross Revenues Generated
    from each.

      Terminal Location                  O/B          O/L/A     % G.R.
                                          /                          %
                                          /                          %
                                          /                          %
                                          /                          %

D - Scope of Operations

    List Major Lanes of Traffic (Point of Origin to Point of Destination)
    And Note Percentage of Gross Revenue Generated From Each Movement.
     (Include Both City And State/Indicate Whether Outbound Or Backhaul-O/B)
       From                         To                  O/B    % G.R.
                                                                   %
                                                                   %
                                                                   %
                                                                   %
                                                                   %
                                                                   %



     List Major Cities Regularly Entered Into:


     Note Percentage of Deadhead Miles         %


     Does Applicant Have A Brokerage Operation?
       If Yes, Please Describe:



     Is Coverage to Be Provided Under This Policy?
     What Percentage of Revenue Is From The Brokerage Operation?         %
     What Is The ICC Brokerage Number?


     Does Applicant Haul Any Double Trailers?
     Does Applicant Have Any Oversized/Overweight Operations?
       If Yes, Describe:




 Page 2                                              Presented by W. F. Roemer Insurance, Inc.
                                                                                   May, 2011
q Truckman Application
                MILEAGE BY STATE IN WHICH OPERATIONS ARE CONDUCTED


Alabama                        Alaska                         Arizona
Arkansas                       California                     Colorado
Connecticut                    Delaware                       Dist Columbia
Florida                        Georgia                        Hawaii
Idaho                          Illinois                       Indiana
Iowa                           Kansas                         Kentucky
Louisiana                      Maine                          Maryland
Massachusetts                  Michigan                       Minnesota
Mississippi                    Missouri                       Montana
Nebraska                       Nevada                         New Hampshire
New Jersey                     New Mexico                     New York
N. Carolina                    North Dakota                   Ohio
Oklahoma                       Oregon                         Pennsylvania
Rhode Island                   South Carolina                 South Dakota
Tennessee                      Texas                          Utah
Vermont                        Virginia                       Washington
West Virginia                  Wisconsin                      Wyoming

                                                    Canada:
                                     (Specify   Provinces)




                                                     TOTAL:                                      0


     Radius of Operations Noted As A Percentage of Gross Revenues

                Radius                 % Gross Revenues
            0 -     50 Miles                     %
           51 -    200 Miles                     %
          201 -    500 Miles                     %
          501 - 1,000 Miles                      %
          Over 1,000 Miles                       %

    Average Haul In Miles:         ; Maximum Haul:




 Page 3                                                   Presented by W. F. Roemer Insurance, Inc.
                                                                                        May, 2011
q Truckman Application

    Do You Transport Any Hazardous Cargo?
     If Yes, Describe:


    List Terminals Where Cargo Exposures Exist/Note Average And Maximum
    Values/Note Protection Provided

    Terminal                   Avg/Max Value           Type of Protection
                                    /
                                    /
                                    /
                                    /
                                    /


    Note If Storage Is Maintained At Any Terminal Under Other Than Bill Of
    Lading Form:



Equipment Information:

Do You Own Or Operate Any Equipment Not Listed On Schedule?
  If Yes, Explain:

                         Location #1        Location #2        Location #3
——————————————————————————————————————————————————————————————————————————————
Address
Type of Operation
# Units Stored Inside
Max Values Inside
# Units Stored Outside
Max Values Outside
Is Lot Fenced?
Night Watchman/Guard?

Please Explain Completely If Any Equipment Is Not Garaged Or Stored At The
Above Locations:




 Page 4                                              Presented by W. F. Roemer Insurance, Inc.
                                                                                   May, 2011
q Truckman Application


Private Passenger Vehicles:
  Use of Vehicles: Business Only       ,    Business & Pleasure
  Operated By: Employee Only     , Family        , Spouse


Leased Or Hired: (Attach Samples of Agreements)

  Do You Do Trip Leasing to The Extent That It Comprises More Than 5% of Your
  Gross Receipts?          What Is The % of Total Revenue?    %
If Yes, Explain In Detail:



Equipment Leased Or Hired (Attach Explanation And Samples of Agreements)


Average Duration    Avg Number of   Est Trip Lease     Insurance         With Hold Harmless
  of Trip Lease      Trip Leases     Payments Per     Provided by        Naming Other Party
                       Per Year          Year        Lessor,Lessee        as Add’l Insured?
With Drivers:
   From Others -

      To Others -


Without Drivers:
   From Others -

      To Others -



Describe:

     (A) Any Significant Changes In Your Operations During The Past (4) Years


And (B) Any Anticipated Changes In Your Operation During The Proposed
         Policy Period:




 Page 5                                                 Presented by W. F. Roemer Insurance, Inc.
                                                                                      May, 2011
q Truckman Application


                                                                      Exhibit A
Information For Equipment Summary:

Terminal                   Priv      Serv      Truck         Tractors           Trls/S-Trl
Location                   Pass      Vehs   Own    Lease    Own   Lease         Own   Lease




Leased Tractor/Trailers Noted Leased With Drivers - Permanent Lease Operators
Trip Leased Operators Generate Approximately     % Anticipated Gross Revenue




HISTORICAL UNIT COUNT:     Year       Unit Count
                           —————————————————————




ESTIMATED FUTURE GROWTH:


Re: Automobile Physical Damage (Owned Equipment Only)
    - See Attached Schedule of Vehicles
    - Trailer Interchange Legal Liability
    -   Est # of Days Foreign Trailers In Possession of Insured
    -   Est # of Foreign Trailers In Possession of Insured at Any Time
    - Longest Movement of A Foreign Trailer In Miles




 Page 6                                                Presented by W. F. Roemer Insurance, Inc.
                                                                                     May, 2011
q Truckman Application


                                                                         Exhibit B
INFORMATION FOR FINANCIAL SUMMARY:


Five Year Gross Revenue History:

          Acct            Acct Period                Policy               Policy Year
          Year              Revenue                   Year                  Revenue




Balance Sheet:

         Years
Current Assets                                  Current Liab
Fixed Assets                                    L-Term Liab
Other Assets                                    Shrhldr's Eq
         Total        $   0             $   0                            $     0             $        0


Income Statement:

                          Years
Operating Revenue
Operating Expenses
Operating Income
Other Income (Expense)
Net Income Before Income Taxes
Net Income After Income Taxes




 Page 7                                                   Presented by W. F. Roemer Insurance, Inc.
                                                                                        May, 2011
q Truckman Application

                                                                          Exhibit C
INFORMATION FOR EXPERIENCE SUMMARY:
  (Current Year and Prior Three Years)

Year #3
  Valuation Date:            Liability   Auto Phys    Cargo              Total
  Insurance Policy Period:    CL   #     CL   #       CL   #             CL   #
         -                    CT   OCC   CT   OCC     CT   OCC           CT   OCC
  Insurance Carrier:

  Revenue:                     Amount    Amount         Amount           Amount
  Mileage:                                                                           $    0
  Payroll:
# Power Units:

Year #2
  Valuation Date:            Liability   Auto Phys    Cargo              Total
  Insurance Policy Period:    CL   #     CL   #       CL   #             CL   #
          -                   CT   OCC   CT   OCC     CT   OCC           CT   OCC
  Insurance Carrier:

  Revenue:                     Amount    Amount         Amount           Amount
  Mileage:                                                                           $    0
  Payroll:
# Power Units:


Year #1
  Valuation Date:            Liability   Auto Phys    Cargo              Total
  Insurance Policy Period:    CL   #     CL   #       CL   #             CL   #
         -                    CT   OCC   CT   OCC     CT   OCC           CT   OCC
  Insurance Carrier:

  Revenue:                     Amount    Amount         Amount           Amount
  Mileage:                                                                           $    0
  Payroll:
# Power Units:


Current Year:
  Valuation Date:            Liability   Auto Phys    Cargo              Total
  Insurance Policy Period:    CL   #     CL   #       CL   #             CL   #
          -                   CT   OCC   CT   OCC     CT   OCC           CT   OCC
  Insurance Carrier:

  Revenue:                     Amount    Amount         Amount           Amount
  Mileage:                                                                           $    0
  Payroll:
# Power Units:




 Page 8                                              Presented by W. F. Roemer Insurance, Inc.
                                                                                   May, 2011
q Truckman Application

EXPERIENCE SUMMARY Cont.

Proposed   Year: ................
Proposed   Revenue: .............
Proposed   Mileage: .............
Proposed   Payroll: .............
Proposed   # Power Units: .......

—————————————————————————————————————————————————————————————————————————————



Loss Summary
                                                                          Current
     Amount            Year #3       Year #2          Year #1                 Year
0-5,000                  (     )       (     )          (     )                (         )
5-10,000                 (     )       (     )          (     )                (         )
10-15,000                (     )       (     )          (     )                (         )
15-25,000                (     )       (     )          (     )                (         )
25,001                   (     )       (     )          (     )                (         )
     Totals                $   0         $   0            $   0                  $       0



  Losses In Excess of $25,000 - Please Explain In Detail:




  Has Your Insurance Ever Been Obtained Through An Assigned Risk Plan?
    If Yes, Explain:




  Has Any Company, During the Past Three Years Canceled or Refused to Renew
  Your automobile Insurance Coverage?        If Yes, Please Explain:




  Page 9                                             Presented by W. F. Roemer Insurance, Inc.
                                                                                   May, 2011
q Truckman Application


                          COMMODITIES TRANSPORTED

    List Commodities Transported/Percentage of Revenue Generated By
    Each/And The Average And Maximum Value Per Trailer Load
    ———————————————————————————————————————————————————————————————

COMMODITY                       TL   LTL      %G.R.              AVG/MAX VALUE

                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /
                                                                         /


                                SHIPPERS


List All Major Shippers For Whom This Risk Hauls:




 Page 10                                              Presented by W. F. Roemer Insurance, Inc.
                                                                                    May, 2011
q Truckman Application

REQUIRED FILINGS:                                           Docket #:

  AUTHORITY      DOCKET #   LIAB   CARGO     AUTHORITY    DOCKET #          LIAB    CARGO
ICC                                        Alaska
Alabama                                    Arizona
Arkansas                                   California
Colorado                                   Connecticut
Delaware                                   District of Columbia
Florida -Id#                               Georgia
         -Ss#
Idaho                                      Illinois
Indiana                                    Iowa
Kansas                                     Kentucky Doc#
Louisiana                                  Maine
Maryland                                   Massachusetts
Michigan                                   Minnesota
Mississippi                                Missouri
Montana                                    Nebraska
Nevada                                     New Hampshire
New Jersey                                 New Mexico
New York                                   N. Carolina
N. Dakota                                  Ohio
Oklahoma                                   Oregon
Pennsylvania                               Rhode Island
S Carolina                                 S Dakota
Tennessee                                  Texas
Utah                                       Vermont
Virginia                                   Washington
West Virginia                              Wisconsin
Wyoming
                                           Canada:
                                           Canada:
                                           Canada:



Indicate All Areas In Which Units Are Operated:

   Atlanta                    Baltimore                       Boston
   Buffalo                    Charlotte                       E. Chicago Indiana
   Cincinnati                 Cleveland                       Dallas/Ft Worth
   Denver                     Detroit                         Hartford
   Houston                    Indianapolis                    Jacksonville
   Kansas City                Little Rock                     Los Angeles
   Louisville                 Memphis                         Miami
   Milwaukee                  Minneapolis/St Paul             Nashville
   New Orleans                New York City                   Oklahoma City
   Omaha                      Phoenix                         Philadelphia
   Pittsburgh                 Portland                        Richmond
   St. Louis                  Salt Lake City                  San Francisco
   Tulsa                      Pacific Coast                   Mountain
   MidWest                    SouthWest                       North Central
   MidEast                    Gulf                            SouthEast
   Eastern                    New England                     Canada


 Page 11                                                   Presented by W. F. Roemer Insurance, Inc.
                                                                                         May, 2011
q Truckman Application
For Safety Summary:

Please Provide Name, Title and Years of Experience of Person(S) Responsible
for Safety. Specify Other Duties.
                  Safety Director
                           Name:
                          Title:
                      Years Exp:
                   Other Duties:

                 Does The Above Have Absolute Power to Hire & Fire?



How Often Are Safety Meetings Held?
           Is Attendance Mandatory?

Do Your Driver Selection Procedures Include:
  A. Written Applications? .......
  B. Reference Checks? ...........
  C. Written Test? ...............           Certificates?.....
  D. Road Test? ..................           Certificates?.....
  E. Physical Exam:
     1) Pre-Employment? ..............................
     2) Federal DOT Requirements? ....................
     3) State DOT Requirements? ......................
     4) Periodically During Employment?    ..(Specify)
  F. Obtaining Driver MVR Records?       Pre-Employment       Post Employment
  G. Updating MVR Records Periodically During Employment?       Specify.

       What MVR Violations Disqualifies A New Prospect?

       What MVR Violations Will Cause Dismissal?

     Are There Any Current Drivers With Convictions For DUI, DWI, or
      Reckless Driving?        (If Yes, Attach MVRs.)
  H. Drug Testing?         During Employment?


Does   Driver Indoctrination Include:
  A.   Company Rules and Policies? ...............
  B.   Daily DOT Vehicle Inspection Procedures? ..
  C.   Equipment Familiarization? ................
  D.   Route Familiarization? ....................
  E.   Emergency Procedures? .....................
  F.   Accident Reporting Procedures? ............




 Page 12                                                  Presented by W. F. Roemer Insurance, Inc.
                                                                                        May, 2011
q Truckman Application


Drivers Leased From a Leasing Company? ........
   If Yes, Give Name, Address of Company and any Details:




Does   Road Supervision Include:
  A.   Mechanical Recording Devices? .............
  B.   Radio Dispatch? ...........................
  C.   Road Patrol By Insured? ...................
  D.   Commercial Road Supervision? ..............


Does   Risk Permit Non-Employee Passengers? ......
Does   Risk Have a Safety Bonus?      What Type of Bonus?
Does   Risk Have a Review Board?      How Often Reviewed?
  By   Whom? .....................................


Are Accident Investigation And Review Procedures, Including Records,
 Maintained?       Do The Review Procedures Include Disciplinary
 Procedures?       If Yes, Please Explain:




Attach Copies of Latest DOT or Applicable State Authority Inspection Reports,
  If Such Inspections Are Made.




 Page 13                                               Presented by W. F. Roemer Insurance, Inc.
                                                                                     May, 2011
q Truckman Application

For Maintenance Summary:


Do You Have a Written Maintenance Program?         If Yes, Please Attach a Copy.

Do You Service Your Own Vehicles?         If No, Who Does?

Type of Repairs Done - Body:            Engine - Major:           Minor:

How Many Mechanics Do You Employ?

Are Units Inspected By Driver?      , If Yes, How Often?


Do You Service Vehicles of Others? .......................
Do You Store Vehicles of Others? .........................

If You Service or Store Vehicles of Others, What Is The Maximum Value Of
Equipment of Others On Your Premises? ....................


Does Vehicle Maintenance Program Include The Following?

  A.   A Service Record of Each Vehicle ......(Attach Copy)

  B.   Controlled Inspection Frequency ....................

  C.   Vehicle Daily Condition Reports ...... (Attach Copy)

  D.   The Above For Leased Vehicles ......................

  E.   At Terminal Inspection .............................

  F.   Are Front Axle Brakes Operative On All Units .......

How Often Are These Reports Reviewed By Management? ......




 Page 14                                                  Presented by W. F. Roemer Insurance, Inc.
                                                                                        May, 2011
q Truckman Application
                            PROPOSED INSURANCE PROGRAM
REQUESTED COVERAGES:

  I - Liability

      A - Comprehensive General                          Limit
      Inc Broad Form Comprehensive General

      B - Comprehensive Automobile                       Limit

      Automobile Medical Payments                        Limit                  P/P only
      Uninsured Motorist                                 Limit - STAT           P/P only

  II - Automobile Physical Damage

       A -    Comprehensive.......ACV...Ded -..                   ...Veh Type..
       A -
       B -    Specified Perils....ACV...Ded -..                   ...Veh Type..
       B -
       C -    Collision...........ACV...Ded -..                   ...Veh Type..
       C -
       D -    Trailer Interchange Legal Liability         Max Limit
       Inc    Specified Perils ACV Ded - T/I S/P /Collision ACV Ded - T/I Coll

                                                                   Veh/Term/Cat
      III - Motor Truck Cargo                    Limit                /     /
         Bill of Lading Form          Deductible -

                                                                  OCC/AGG
      IV - Umbrella Liability                   Limit               /




                                                         Term                     Amount
   Cost Factors (Projected Gross Revenues                                                     )

            Guaranteed Cost Program

            Deductible Program
                 Deductible – Liability                                                 Per OCC
                               Automobile Physical Damage                               Per OCC
                               Motor Truck Cargo                                        Per OCC

   Note -

     If Deductible Program Is Elected Indicate Automobile Physical Damage
     And Cargo Deductible Amounts Under Cost Factors, Not Coverages.




 Page 15                                                         Presented by W. F. Roemer Insurance, Inc.
                                                                                               May, 2011

				
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