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Producer Work for Hire

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					                                         COMMERCIAL AUTO APPLICATION
                 SUPPLEMENTAL HIRED & NON-OWNED "AUTOS" APPLICATION
                               PACKAGE DELIVERY / GROUND COURIER PROGRAM

        DATE

                     APPLICANT NAME                                                                                 BROKERAGE

                             DBA                                                                                     PRODUCER

"Private Passenger Type"(PPT) - For the purpose of classifying Hired and Non-Owned "Auto" types, a "Private Passenger Type"(PPT)
"auto" means an "auto" of the sedan, station wagon, van, pickup or sport utility (SUV) type manufactured for use as a private passenger
"auto" and has not been equipped or modified for business use purposes.


INSURANCE INDUSTRY DEFINITION OF "HIRED" AUTOS
Symbol - 47 or 68 (Truckers or Motor Carrier Coverage Form) =
    Only those "autos" you lease, hire, rent or borrow. This does not include any "private passenger type" "auto" you lease, hire, rent or
    borrow from any member of your household, any of your employees, partners or agents or members of their households.


      "HIRED" "AUTOS" INCLUDE OWNER OPERATORS OPERATING FOR YOU WITH THEIR VEHICLE AND TYPICALLY BEING
      PAID BY THE ROUTE, STOP OR PERCENTAGE OF REVENUE REFLECTED ON A 1099.

      Based on the definition above, my company                        does              does not have an exposure for hired "autos".

INSURANCE INDUSTRY DEFINITION OF "NON OWNED" "AUTOS"
Symbol 50 or 71 (Truckers or Motor Carrier Coverage Form) =
    Only those "autos" you do not own, lease, hire, rent or borrow that are used in connection with your business. This includes "private
    passenger type" "autos" owned by your employees or partners or members of their households but only while used in your business or your
    personal affairs.

      "NON-OWNED" AUTOS DOES INCLUDE AN EMPLOYEE OPERATING THEIR VEHICLE FOR YOUR FIRM FOR ROUTE
      WORK. TYPICALLY THIS EMPLOYEE WOULD BE COMPENSATED HOURLY FOR LABOR AND MILEAGE, BY THE ROUTE
      OR DAILY FOR THEIR VEHICLE. THIS GROUP TYPICALLY RECEIVES A 1099 FOR VEHICLE COMPENSATION AND A W-2
      FOR WAGES AT YEAR END.

      Based on the definition above, my company                        does              does not have an exposure for "non-owned" "autos".

      INSURANCE INDUSTRY DEFINITION OF "COST OF HIRE":
      1) The total dollar amount of costs you incurred for the hire of automobiles (includes trailers and semi-trailers), and if not included therein,
      2) The total remunerations of all operators and drivers helpers, of hired automobiles whether hired with a driver by lessor or an employee of
      the lessee, or any other third party, and 3) The total dollar amount of any other costs (i.e. repair, maintenance, fuel, etc.) directly associated
      with operating the hired automobiles whether such costs are absorbed by the insured, paid to the lessor or owner, or paid to others.



      TRANSLATION: "Cost of Hire" is the total direct cost to your company of operating the vehicles regardless to whom or for what reason the
      money was paid.

A.    "HIRED" "AUTOS" WITH A DRIVER: ("Owner Operators")
          History of Exposure
                  12 Month Period       "Cost of Hire" *                                        Mileage                         Gross Revenue
              Projected next 12 months                                                                                    $
                 Current 12 months                                                                                        $
                  Prior 12 months                                                                                         $
                  Prior 12 months                                                                                         $
                  Prior 12 months                                                                                         $
                  Prior 12 months                                                                                         $



     Package Delivery / Ground Courier Program                          Page 1 to 4                        f6671171-86e7-4b0e-b36e-14bddc180fb4.xls
                                           COMMERCIAL AUTO APPLICATION
               SUPPLEMENTAL HIRED & NON-OWNED "AUTOS" APPLICATION
                             PACKAGE DELIVERY / GROUND COURIER PROGRAM

      DATE

                  APPLICANT NAME                                                                           BROKERAGE

                           DBA                                                                             PRODUCER
                                            HISTORY OF HIRED AND NON-OWNED "AUTOS"

                                                  Number of "Autos" by Type / Weight / Radius
                                               Projected Next   Current 12       Prior 12       Prior 12        Prior 12         Prior 12
         Type / Weight / Radius
                                                 12 Months       Months          Months         Months          Months           Months
        "Non-Owned" "Auto"

                                    0-50
"Private Passenger Type"
           **                   51-200

                                 > 200
            "Hired" "Auto"

                                    0-50
"Private Passenger Type"
           **                   51-200

                                 > 200

                                    0-50
      Light Trucks
  0-10,000 lbs G.V.W.           51-200

                                 > 200

                                    0-50
     Medium Trucks
10,001-20,000 lbs G.V.W.        51-200

                                 > 200

                                    0-50
      Heavy Trucks
20,001-45,000 lbs G.V.W.        51-200

                                 > 200

                                    0-50
  Extra Heavy Trucks
  > 45,000 lbs G.V.W.           51-200

                                 > 200

                                    0-50
     Heavy Tractors
20,001-45,000 lbs G.V.W.        51-200

                                 > 200

                                    0-50
  Extra Heavy Tractors
  > 45,000 lbs G.V.W.           51-200

                                 > 200
         Trailers & Semi-trailers

   Package Delivery / Ground Courier Program                       Page 2 to 4                    f6671171-86e7-4b0e-b36e-14bddc180fb4.xls
                                        COMMERCIAL AUTO APPLICATION
                 SUPPLEMENTAL HIRED & NON-OWNED "AUTOS" APPLICATION
                               PACKAGE DELIVERY / GROUND COURIER PROGRAM

        DATE

                    APPLICANT NAME                                                                                BROKERAGE

                             DBA                                                                                  PRODUCER

B.    Provide a brief description of where the "autos" operate (perform their transportation services), and if applicable, how many have team
      drivers and/or pull double or triple trailers.




C.    Basis of Remuneration - Hired and Non-owned

                HIRED                NON-OWNED

                                                          Hourly Wage only:           $                per hour

                                                          Hourly Wage:                $                per hour, plus
                                                                                      $                per mile, plus other $

                                                          Mileage rate only:          $                per mile

                                                          % of Gross Revenue:                          %

                                                          Other (Describe):


D.    Exposure basis per driver - "Hired" and "Non-Owned" "Autos"

                HIRED                NON-OWNED

        1)                                           Number of full-time drivers (40 or more hours per week)

        2)                                           Number of part-time drivers (less than 40 hours per week)

        3) Each driver averages,

                                                     hours per week,
                                                     miles per week and
         $                       $                   total remuneration per week.

        4) Percentage of drivers who operate:

                       %                         %   Less than 25 hours per week
                       %                         %   25 - 40 hours per week
                       %                         %   40 - 50 hours per week
                       %                         %   Greater than 50 hours per week

E.    Do you require written contracts for "Hired" and "Non-Owned" "Autos"?                          Yes                No
      If "Yes" attach a complete copy (with addendums, attachments and supplements) to this application.




     Package Delivery / Ground Courier Program                        Page 3 to 4                      f6671171-86e7-4b0e-b36e-14bddc180fb4.xls
                                         COMMERCIAL AUTO APPLICATION
                 SUPPLEMENTAL HIRED & NON-OWNED "AUTOS" APPLICATION
                               PACKAGE DELIVERY / GROUND COURIER PROGRAM

        DATE

                     APPLICANT NAME                                                                              BROKERAGE

                             DBA                                                                                   PRODUCER

F.    Do you require proof of liability insurance coverage from owners of Hired and Non-Owned "autos"?                               Yes       No
      If "Yes", indicate all that apply for the form of proof and limits of coverage required.

                HIRED               NON-OWNED

                                                     "Autos" are only required to carry the state required minimum Auto Liability Limit

                                                     "Autos" are required to carry higher limits of insurance coverage described below

                                                         $                          each person Bodily Injury
                                                         $                          Any one Accident Bodily Injury and
                                                         $                          Any one Accident Property Damage, or
                                                         $                          Combined Single Limit ("CSL") any one Accident

                                                     They provide me with a copy of their insurance card

                                                     They provide me with a copy of their declaration page

                                                     They provide me with a Certificate of Insurance naming my firm Certificate Holder


                                                     They provide me with a Certificate of Insurance naming my firm Additional Insured


G.    Do you allow passengers to ride with drivers while performing work for you?                            Yes         No

      If yes, describe the circumstances and procedures for allowing passengers.




H.    Do you allow substitute drivers?                       Yes     No

      If yes, describe your provisions for substitute drivers.




 This application supplement must be signed by a company officer. Completion of this Supplemental Application section does not guarantee
coverage. This application may become part of an insurance policy, if issued.




               PRINT NAME                                                 SIGNATURE                                    TELEPHONE NUMBER




     Package Delivery / Ground Courier Program                        Page 4 to 4                        f6671171-86e7-4b0e-b36e-14bddc180fb4.xls

				
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