Business Owner's Name*
First
Last
SMS Consent
Business Information Business Type Mailing Address*
Garaging Address*
Same as Mailing Address
Shipping Address*
Same as Mailing Address
Federal Filings State Filings Have You Been Cancelled or Non-Renewed
Vehicles List* Trailers List Drivers List* Include yourself, whether you are a driver or not.
Coverage Options Auto Liability* Non-Trucking Liability (Bobtail)* Motor Truck Cargo* Driver Error Non-owned Trailer (PD or TI)* Trailer Interchange Agreement?* Truckers General Liability Work Comp Employee Coverages Other Property ELD? Extra questions 10+ Units?
MFM Items being hauled as part of your operation Do operators take units home? Security measures you take
Historical Operating Information
BizChoice Requested Coverage Do all drivers have 2 years experience driving similar equipment? Technology installed in all vehicles DO YOU UTILIZE INDEPENDENT CONTRACTORS? IC agreement require a compatible ELD device? Do your IFTAs reports include independent contractor mileage? Do current contractors have compatible ELD reported with your IFTAs miles? If no, does IC agreement require contractors to report IFTAs miles quarterly? Are ICs required to purchase truckers liability or bobtail coverage? Do ICs purchase physical damage coverage themselves? Do you provide Workers Compensation for employees? Do you provide Occupational Accident for employees? Do you conduct a road test? In-house or outside maintenance provider? Ever been cancelled for non-payment of premium? Filed for bankruptcy in the last 7 years?
Section 3 - Workers Compensation / Occupational Accident Do you currently have Workers Compensation coverage? Does it include coverage for you? How are you paid? Reside or conduct business in ND, OH, WA, or WY? All contractors/drivers/qualified drivers between age 21 and 70? All helpers between age 18 and 70? Do you ever use helpers? Ever use more than 1 helper per delivery? Ever use more than 2 helpers per delivery?
WHAT % OF CARGO REVENUE IS RELEASED BETWEEN:
TYPES OF GOODS HAULED:
JMS - Operations Questionnaire Size of Business Any losses in the past 3 years? (provide supporting loss runs) Do you pull doubles? Do you pull triples? Operate as a broker or freight forwarder? Do you allow passengers? Transport any hazardous commodities/waste? Are employees covered by work comp? 5+ trucks?
Additional Questions for Prospects with 5+ Units Special equipment mounted or attached? Significant change to operations in the last 12 months? Does management review all incidents resulting in a loss?
ENVIRONMENTAL TRANSPORTATION - Questions Carrier Type
Operations (operation type and commodity must total 100%) Any vehicles used for dumping, logging, transit mix, or waste disposal?
Mileage Radius (% of tractor miles)
Hazardous Materials & Operations Haul any hazardous materials? Registered to haul hazardous materials? Written emergency spill plan for drivers? Deliver products to rail yards, marinas, or airports? If yes, load/unload directly onto trains, watercraft, or aircraft? Provide all DOT hazmat training plus refresher courses? Any special filings required? Drivers trained to assure liquids unloaded into proper tank? Transport high-value equipment or oversized/overweight loads? If yes, escort or pilot vehicles required? Insurance lapsed, canceled, or non-renewed in last three years? Act as freight forwarder, freight broker, or arrange loads for others? Haul double or triple trailers? Allow guest passengers? (attach passenger policy) Do you have a safety manager? If yes, full-time?
Active Safety Controls (% of fleet equipped)
General Liability On-premises fuel storage? If yes, storage below ground? Do you operate from a residence?
Coverages Desired Desired covered auto symbol(s) Additional Cargo Coverages/Endorsements If Enhanced Reefer, are all units company-owned?
Hartford - Coverage Requested Type of Coverage Requested Optional Coverage Extension(s)
Operations Are state filings required?
Livestock Hauled (%) Transport any special valued animals? Transports for any of the following
Lancer - New Venture Questions Describe accidents 'not at fault' (date, amount paid, amount reserved)
Describe accidents 'at fault' (date, amount paid, amount reserved)
Does any other member of the corporation hold a CDL? (if yes, MVR required) Future Goal Are you applying for ICC authority?
Lancer Non-Fleet Questions All owned or leased equipment scheduled on this application? All equipment operated under applicant's authority scheduled? Intend to add units this year? Do you pull Double Trailers? Do you pull Triple Trailers? Are loaded trailers ever left unattended? Do you spot trailers?
Drivers Do you now or intend to hire owner operators? Do you now or intend to hire team drivers? Is this a New Venture? (if yes, complete New Venture Profile) Rental Reimbursement Days of Coverage
Loss History Loss History (Term From/To, Liability #Claims/Amt, Physical Damage #Claims/Amt, Cargo #Claims/Amt, GL #Claims/Amt)
Loss runs attached? Any underground or above ground storage facilities? Sell any product wholesale or retail?
LANCER FLEET TRUCK APPLICATION (4+ UNITS) Routes/Areas Traveled Through or Into
Commodities Transported
Operations Act as a freight-broker or freight-forwarder or arrange loads for others? All scheduled equipment owned by you? Do you service your vehicles?
Driver Information Utilize team drivers?
TRUCK FLEET-NUMBER OF DRIVERS
NUMBER OF DRIVERS HIRED OR LEASED LAST YEAR Written test? Road test? Drug testing - Ongoing? Drug testing - Random?
Safety Information Driver safety meetings? All drivers required to attend? Policy to allow passengers in truck-tractor with drivers?
Garaging Address Information Fenced Security Guards Public Access Lighted Guard Dog(s) Owned or leased? All the above information is accurate and true to the best of my knowledge.* Consent* Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.
I Agree
