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In Pennsylvania West Virginia Fleet

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					                                                                                                            In Pennsylvania & West Virginia:
Fleet                                                                                                   2307 Menoher Blvd., Johnstown PA 15905
Transportation                                                                                             (800)452-0297 FAX (814)255-6010
                                                                                                                      In Maryland:
Application                                                                                                    111 Warren Road, Suite 1B
                                                                                                                 Cockeysville, MD 21030
                                                                                                           (800) 759-7779 FAX (814) 628-6914
Policies Will Not Be Issued Without SSN/FEIN#
This application can be processed without delay if the following documents are provided:
A. Currently valued insurance Company                                                                      Coverages Desired:
B. A completed equipment schedule showing vehicle type, make, model and values.                              Auto Liability
C. A copy of current MVR’s for all drivers on all new business.                              New             Physical Damage
D. Schedule B fuel tax report for last year.                                                 Renewal         Cargo
1. Name:                                                             2. Physical Address:
3. Mailing Address:
4. Social Security Number or Federal Tax ID              5. Business Phone Number:
Number:
6. Date Coverage Desired:                                7. Who should we contact for a loss control       8.     Phone Number:
                                                              inspection?:

9. Applicant is:     Corporation    Partnership     Joint Venture    Individual      Other:
10. How many years does applicant have with truck insurance in own name as owner of business?
11. Loss Experience       Provide the following insurance information for the past three years or submission will not be processed.
Has any Insurance company cancelled or non-renewed your policy in the past three years?        Yes    No
Is current Carrier non-renewing?     Yes     No
If yes, explain:
Prior 3     Insurance       Policy           Coverage         Prior 3 Yrs Amount &          Prior 3 Yrs Amount         Driver(s) Involved in Loss(es)
Yrs         Company         Number                            Number of Liability           & Number of Phys.
                                                              Losses                        Damage Losses




Operations
a. Commodities Hauled:
b. Gross Revenue: Last 3 Years:            -$             -$                 -$
c. Mileage: Last 3 Years:         -               -               -
d. # of Units Operated: Last 3 Years:           -             -                -
e. Prior Fleet Values: Last 3 Years:          -$             -$                 -$
f. Estimates for next policy year: Revenue: $          Miles:
g. Do you pull any Double Trailers?         Yes     No If Yes, What Percentage?        %
h. You are a:     Common Carrier        Contract Carrier
i. Do you pull any Triple Trailers?     Yes       No If Yes, What Percentage?        %
j.    Is all commercial equipment you own or operate described in the application?     Yes      No
      If No, Explain:
k. Radius of Operations: 0 to 100 miles           % 101 to 300 miles             % 301 to 500 miles       %         Over 500 Miles       %
i. Check cities served by showing % of overall operations to each:                            Miami                 Portland
       Atlanta                     Cincinnati                   Houston                  N.Y.City                   Richmond
       Balt.-Wash.                 Cleveland                    Indianapolis             Oklahoma                   St. Louis
                                                                                         City
       Boston                      Dallas/                      Jacksonville             Omaha                      Salt Lake
                                    Ft.Worth                                                                        City
       Buffalo                     Denver                       Kansas City              Phoenix                    San
       Charlotte                   Detroit                      Little Rock              Philadelphia               Francisco
       Chicago                     Hartford                     Los Angeles              Pittsburgh                 Tulsa
13. Driver Information            Must be completed for all drivers or            Information for additional drivers should be attached.
                                  submission will NOT be processed.
Current Number of Drivers:         Turnover in the last 12 mos.: Replaced:       Added:
Driver             Date of         License             # Yrs.          # Yrs.          # Accidents        In Last 3      License Suspended/ Revoked
                   Birth           Numbers             Employed by Comm’l                                 Years #
                                                       you             Driving Exp.                       Violations




14. Driver’s pay is calculated by:   Trip    Hourly     Other (explain):
15. Driver’s maximum hours: a. Driving          daily,       weekly
                                b. On duty       daily,      weekly
16. Equipment (List number of owned or leased units of each type)
Classification        Trucks               Tractors             Semi-Trailers                                   Other:
Company Owned
                                                                                                                         Page 1 of 6
    or Leased
    Long Term Lease
    With Drivers
    Totals
    17. Please complete the schedule of vehicles on pages 5 and 6.
    18. Does Motor Carrier Act apply to you?
        No, why not?
       Yes, please attach the MCS-90 Endorsement to my policy as:
            Type 1 Nonhazardous Commodities         Type 2 Hazardous Commodities
            Type 3 Hazardous Commodities
    Leasing/Brokerage/Trailer Interchange:                            Provide copies of lease or agreements
    19. Do you trip lease to other carriers?    Yes     No If Yes, list carriers:
    20. Revenue when trip leased past 12 months:          Estimate next 12 months:
    21. Do other carriers trip lease to you?    Yes     No
    22. Revenue paid to hired trucks last 12 months:         Estimate next 12 months:
    23. Are you full-tim leased?       Yes   No if Yes, to whom?
         Are you responsible for Primary Insurance Coverage?       Yes      No
    24. Do you operate as a freight broker, freight forwarder or arrange loads for others?     Yes    No
         If Yes, provide brokerage name and docket number:
         Annual Brokerage Revenue: $            What % of your operation is brokerage?          %
    Trailer Interchange: Do you use non-owned trailers?      Yes     No       How many per week?
    Per year?
    25. Maximum value             Average value
          Are you responsible for Physical Damage?      Yes     No
    27. Written Agreement           Other        Provide copies of written agreements
                                                           Motor Truck Cargo
    28. Cargo Insurance Requested:               Commodity                 % of Total     Value Per Truck Load
         Amount $                                Transported               Revenue        Maximum Average
         Deductible $




    29. Current Carrier:
        Current Rate:
    30. Terminal             Limits of            Avg. Value at      Construction       Protection (*)
    Locations                Liability            Terminal

                                                                                    (*)Protection – i.e., fenced, guards, open 24 hours, etc.
                                                         Maintenance Information
    31.   Do you have a written maintenance program?       Yes     No If Yes, attach a copy.
    32.   Do you service your own vehicles?      Yes     No
          If Yes, How many mechanics do you employ?            If No, who does?
    33.   Does vehicle maintenance program include the following:
          A. A service record of each vehicle?      Yes    No
          B. Controlled Inspection frequency? Yes          No
          C. Vehicle daily conditions reports (attach copies)? Yes      No
          D. The above for leased vehicles      Yes     No
    34.   How often are these various reports reviewed by management?

   Safety Information
   Attach copies of latest DOT or applicable state authority inspection reports, if such inspections are made. Answer ALL questions
   or submission will NOT be processed.
   35. Do your Driver selection procedures include:
   A. Written Applications?                                    Yes     No
   B. Reference Checks?                                        Yes     No
   C. Written Test?                                            Yes     No Certificates? Yes             No
   D. Road Test?                                               Yes     No Certificates? Yes             No
E. E. Physical Exams:
F.     (1) Pre-Employment?                                     Yes     No
                                                                                                         Page 2 of 6
    (2) Federal DOT Requirements?                                         Yes       No
    (3) State DOT Requirements?
    (4) Periodically during employment?                                   Yes       No      If No, please specify how often:
                                                                          Yes       No
F. Review MVR before hiring or leasing Driver?                            Yes       No
G. Updating MVR records periodically during                               Yes       No      Specify how often:
   employment?
H. Drug Testing?                                                          Yes       No      During Employment?
                                                                                              Yes    No
36. Does Driver indoctrination
    include:
A. Company rules and policies?                                            Yes       No      D. Route Familiarization?
                                                                                                  Yes     No
B. Daily DOT vehicle inspection procedures?                               Yes       No      E. Emergency procedures?
                                                                                                  Yes     No
C. Equipment familiarization?                                             Yes       No      F. Accident reporting
                                                                                               procedures? Yes        No
37. Does road supervision include:
A. Mechanical recording devices?                                          Yes       No      C.    Radio Dispatch?
                                                                                                    Yes     No
B. Computer/satellite tracking?                              Yes      No
38. Are accident investigation and review procedures, including records, maintained? Yes                                 No
    Does the revies procedures include disciplinary procedures? Yes        No
    If Yes, explain
39. Is it the policy of the applicant trucker to allow passengers to ride  Yes     No
    in the truck – tractor with the drivers?
                                                         Insured Agreement
Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer submits an application or files a claim containing false or
deceptive statements is guilty of insurance fraud.
This applicant agrees to furnish promptly the driver data for every driver engaged during the policy period. Applicant, Agent or Broker understand and agree that no
flat cancellation will be allowed and either or both guarantee payments of earned premium to final termination date of policy or of any filing made by the company on
behalf of the Applicant.
In consideration of the premium changed for the policy for which this application is made, and the Company attaching to said policy, either the endorsements required
by any State Commission or Interstate Commerce Commission, or both, it is agreed as between the company and the undersigned that all the provisions and agreements
of the policy shall be in full force and effect the same manner as if the said endorsement had not been attached. The Named Insured further agrees that the said policy
shall not and does not protect the Named Insured against claims for injury, damage or loss sustained by any person when not caused by a motor vehicle specified in said
policy, and if the Company shall be obliged to pay any claim that it would not be obliged to pay if said endorsement had not been attached, the Insured agrees to
reimburse the company in the amount paid and all sums including costs and expenses which shall have been paid in connection with such claims.
I, The Applicant, understand the Insurance Producer assisting me with the placement of this Insurance coverage is not an appointed agent of the Insurer and does not
have authority to bind coverage.
Coverage will be effective only when bound by the General Agency in writing.

General Agent:                   Applicant for Insurance                      Title
Interstate Insurance Management, Inc.
                                 Signed at (City)        (State)
2307 Menoher Boulevard
Johnstown, PA 15904              Date
                                  IMPORTANT: Prompt Reporting of Accidents is Required.
                                                    Request for Filings
Please :   Make    Amend*       Cancel**    Reinstate     Refile    Renew
*Reason for Amend:                                  **Reason for Cancel:
Do you have ICC authority? Yes      No              If Yes, Docket Number:
Do you have Brokerage authority? Yes      No        If Yes, under what name & Docket Number:

                                                            Insurance Carrier:
                                                    Name & Address Information for Filings
State         Docket or Permit          Applicant’s Name & Address as it Appears on Each Permit




                                                                                                                        Page 3 of 6
L = Liability C = Cargo
L     C                                                        L       C
             Alabama                                                          New Mexico – Docket #         ($15 fee)
                                                                                        Payable to: New Mexico State
                                                                                        Corp. Comm.
             Arizona                                                          New York – Intra State Only
             Arkansas                                                         North Carolina
             California -       ICC Exempt Only                               North Dakota– Intra State Only
                            -      EX #
                            -      Intra State Only
             Colorado                                                         Ohio
             Connecticut                                                      Oklahoma ($15 fee) O.C.C. #
                                                                                       Payable to: Oklahoma Corp.
                                                                                       Comm.
             Florida                                                          Oregon
             Georgia FEI#                                                     Pennsylvania – Intra State Only
             Idaho – Intra State Only                                         Rhode Island – Intra State Only
             Illinois – ($25 fee)                                             South Carolina
                       Payable to Illinois Commerce
                       Commission
             Indiana – PSCI#                                                  South Dakota
             Iowa                                                             Tennessee
             Kansas                                                           Texas ($100 fee – Form E only)
                                                                                      Payable to: Texas Railroad
                                                                                      Commission
             Kentucky – KYU#                                                  Utah
             Louisiana                                                        Virginia – Intra State Only
             Maine                                                            Washington
             Michigan – Intra State Only                                      West Virginia – WV Licensed Only
             Minnesota                                                        Wisconsin
             Mississippi                                                      Wyoming – Intra State Only
             Missouri                                                         ICC (Cargo Common Carrier Only)
             Montana – Intra State Only
             Nebraska
             Nevada – Intra State Only
Oversize/Overnight Liability:
Canadian Province(s):




                                                                Coverage Information
Applicant Name:
Liability Coverages                                                Physical Damage Coverages
  Truckers Liability $      CSL                                       Specified Perils, Deductible $
  Non-Truckers Liability $       CSL                                  Collision, Deductible $
  Medical Payments $                                                  Trailer Interchange, Limit $
  *Uninsured Motorist $                                                  Symbol #48 Symbol #49
  *Underinsured Motorist $                                            Rental Reimbursement Limit $      per
  *Personal Injury Protection $                                          10 Day 20 Day 30 Day
  Hired Auto                                                       * Complete and Attach Selector Forms
  Non-Owned Auto No.
  Cargo (See Application)
  Pollution
  Lessee Coverage: 10%          20%
                    30%         of operations
                                                                      Vehicle Schedule
Veh. #      Year       Make, Model, Body Type            Zone             Terr.    Misc. Type           VIN/Serial Number

Zip Where                   Stated Amount             Radius                   GVW/GCW                   Loss Payee Name:
Garaged:

Veh. #      Year       Make, Model, Body Type            Zone               Terr.      Misc. Type       VIN/Serial Number

Zip Where                   Stated Amount             Radius                   GVW/GCW                   Loss Payee Name:
Garaged:

                                                                                                                    Page 4 of 6
Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

                                          Vehicle Schedule - Continued
Veh. #   Year   Make, Model, Body Type   Zone         Terr.    Misc. Type   VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:
Garaged:

Veh. #   Year   Make, Model, Body Type   Zone        Terr.    Misc. Type    VIN/Serial Number

Zip Where         Stated Amount      Radius             GVW/GCW             Loss Payee Name:

                                                                                   Page 5 of 6
Garaged:

Veh. #     Year   Make, Model, Body Type   Zone   Terr.   Misc. Type   VIN/Serial Number

Zip Where           Stated Amount      Radius        GVW/GCW           Loss Payee Name:
Garaged:

Veh. #     Year   Make, Model, Body Type   Zone   Terr.   Misc. Type   VIN/Serial Number

Zip Where           Stated Amount      Radius        GVW/GCW           Loss Payee Name:
Garaged:

Veh. #     Year   Make, Model, Body Type   Zone   Terr.   Misc. Type   VIN/Serial Number

Zip Where           Stated Amount      Radius        GVW/GCW           Loss Payee Name:
Garaged:

Veh. #     Year   Make, Model, Body Type   Zone   Terr.   Misc. Type   VIN/Serial Number

Zip Where           Stated Amount      Radius        GVW/GCW           Loss Payee Name:
Garaged:




                                                                              Page 6 of 6

				
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Description: Semi Truck Driver Lease Agreement document sample