ACORD 132 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 132 (2008/09) Truckers / Motor Carriers Section ACORD 132, Truckers / Motor Carriers Section, is designed to handle the basic underwriting and rating needs for liability and physical damage coverages for trucking or motor carrier operations. If a transportation or motor truck legal liability exposure exists, the Transportation Section, ACORD 143, may also need to be completed. Insurance coverages, “no fault” and uninsured / underinsured motorists coverages in particular, vary widely from state to state. In addition, there are numerous state-specific requirements that apply to Truckers or Motor Carrier applications. ACORD 132 cannot address these various unique specifications. Therefore, state specific forms, ACORD 137, have been developed to respond to these requirements. Use the ACORD 137 for your state to provide coverages / limits information, as well as the required disclosure and other data unique to the state. See the State Forms FIG for more information.
TITLE Truckers / Motor Carriers Section This form was designed to be used in conjunction with ACORD 125,Commercial Insurance Application – Applicant Information Section and ACORD 129, Vehicle Schedule. Please see the FIG for these forms for specific information on completing them. Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in all states.
IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer’s name.
IDENTIFICATION SECTION Policy Number The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier Name of the insurance company (or residual market plan) that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Named Insured(s) Full name of the applicant as it should appear on the policy and all names that appear on the title for the vehicle.
IDENTIFICATION SECTION Effective Date: Enter the effective date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
PRINCIPAL SHIPPERS Principal Shippers Include the names of shippers frequently serviced by the applicant.
REGULATION This section is used to indicate the relationship between the applicant and the property being shipped and to indicate any regulatory filings required. Indicate the method of operation by checking the applicable box(es). Also attach ACORD 194, Request for State/Federal Filing Action, to provide the necessary filing information.
REGULATION Common Carrier Has the general rights to operate as a carrier for any shipper over certain routes and for types of non-exempt commodities.
REGULATION Contract Carrier Has the rights to haul interstate for certain specific customers. The trucker is limited to no more than 10 contracts.
REGULATION Private Carrier Indicates an insurable interest in the property being shipped on owned vehicles or other vehicles while in transit by virtue of ownership.
REGULATION DOT Rating Check this box, if applicable.
REGULATION Docket # Provide the DOT docket number, if applicable.
REGULATION ICC Filing Check this box if an ICC filing is required.
REGULATION Docket # Indicate the ICC filing docket number.
REGULATION Other List any other trucking relationship in detail in the Remarks Section.
COVERAGES / LIMITS Coverages / Limits Use ACORD 137 for your state to provide COVERAGES / LIMITS information.
COVERAGES / LIMITS Covered Auto Symbols Truckers policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to check the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 41 through 45 provide Fleet Automatic coverage. Symbol 41 includes Hired and Non-Owned auto coverage. If symbol 41 is not used and Hired Auto (symbol 47) or Non-Owned Auto (symbol 50) coverage is desired, those symbols must be checked. The symbols indicate the automobiles to which each coverage applies. The symbol “triggers” the coverage. For exact policy definitions of the symbols, please refer to the company’s policy declarations page.
COVERAGES / LIMITS Symbol 41 – Any Auto Can only be used for Liability insurance. Its use provides coverage for any auto with which the insured will have contact, including owned and non-owned and hired vehicles. It includes coverage for non-owned autos, no-fault, uninsured motorists or physical damage insurance.
COVERAGES / LIMITS Symbol 42 – Owned Autos Only Provides coverage for owned autos only and includes automatic coverage for autos you newly acquire.
COVERAGES / LIMITS Symbol 43 – Owned Commercial Autos Only Provides coverage for owned commercial autos only and includes automatic coverage for commercial autos you newly acquire.
COVERAGES / LIMITS Symbol 44 – Owned Autos Subject to No-Fault Laws Applies to owned autos where no-fault is required by law, including automatic coverage for autos you newly acquire.
COVERAGES / LIMITS Symbol 45 – Owned Autos Subject to Compulsory Uninsured Motorist Laws Applies to owned autos where there is a compulsory Uninsured Motorists law including automatic coverage for autos you newly acquire where rejection of UM is not permitted by law.
COVERAGES / LIMITS Symbol 46 – Specifically Described Autos Provides coverage for scheduled autos only, with no automatic coverage for autos you newly acquire.
COVERAGES / LIMITS Symbol 47 – Hired Autos Only Provides coverage only for autos leased, hired, rented or borrowed by the named insured. This does not include autos owned by employees or members of their families.
COVERAGES / LIMITS Symbol 48 – Trailers in Your Possession Under a Trailer Interchange Agreement Provides for trailers listed under a trailer interchange that are left in the applicant’s possession.
COVERAGES / LIMITS Symbol 49 – Trailers in the Possession of Another Trucker Under a Trailer Interchange Agreement Provides coverage for your trailers when listed under a trailer interchange that are in the possession of another trucker.
COVERAGES / LIMITS Symbol 50 – Non-Owned Autos Only Provides liability coverage for autos not owned by the named insured but used in connection with the trucking business. This includes autos owned by employees. Coverage/Limits – Use ACORD 137
RECEIPTS / MILEAGE / UNITS Gross Receipts For each of the past three years, enter the gross receipts. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Total Mileage For each of the past three years, enter the total mileage for all vehicles. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS # Power Units For each of the past three years, enter the total number of power units. Also enter estimates for next year.
COMMODITIES Commodities Transported Describe each of the major commodities transported
COMMODITIES % Total Revenue Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Enter the estimated value per truckload.
RECEIPTS / MILEAGE / UNITS Gross Receipts For each of the past three years, enter the gross receipts. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Total Mileage For each of the past three years, enter the total mileage for all vehicles. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS # Power Units For each of the past three years, enter the total number of power units. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Gross Receipts For each of the past three years, enter the gross receipts. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Total Mileage For each of the past three years, enter the total mileage for all vehicles. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS # Power Units For each of the past three years, enter the total number of power units. Also enter estimates for next year.
COMMODITIES Commodities Transported Describe each of the major commodities transported
COMMODITIES % Total Revenue Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Enter the estimated value per truckload.
RECEIPTS / MILEAGE / UNITS Gross Receipts Previous For each of the past three years, enter the gross receipts. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Total Mileage Previous For each of the past three years, enter the total mileage for all vehicles. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS # Power Units Previous For each of the past three years, enter the total number of power units. Also enter estimates for next year.
COMMODITIES Commodities Transported Previous Describe each of the major commodities transported
COMMODITIES % Total Revenue Previous Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Previous Enter the estimated value per truckload.
COMMODITIES Commodities Transported Describe each of the major commodities transported
COMMODITIES % Total Revenue Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Enter the estimated value per truckload.
RECEIPTS / MILEAGE / UNITS Gross Receipts Previous For each of the past three years, enter the gross receipts. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS Total Mileage Previous For each of the past three years, enter the total mileage for all vehicles. Also enter estimates for next year.
RECEIPTS / MILEAGE / UNITS # Power Units Previous For each of the past three years, enter the total number of power units. Also enter estimates for next year.
COMMODITIES Commodities Transported Previous Describe each of the major commodities transported
COMMODITIES % Total Revenue Previous Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Previous Enter the estimated value per truckload.
COMMODITIES Commodities Transported Describe each of the major commodities transported
COMMODITIES % Total Revenue Enter the percent of total revenues.
COMMODITIES Value Per Truck Load Enter the estimated value per truckload.
TERMINALS This section is used to collect information on the terminal locations that the trucker uses.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
TERMINALS LOC # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number.
TERMINALS Zone # Indicate the zone number of the identified location.
TERMINALS Name and Address of Terminals Enter the name and address of each terminal used.
TERMINALS # Veh Specify the number of vehicles regularly using or garaged at each terminal.
TERMINALS Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging.
DRIVER INFORMATION ACORD 163 Attached Check this box if ACORD 163, Commercial Auto Driver Information Schedule, is attached.
DRIVER INFORMATION This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
DRIVER INFORMATION Name Enter driver’s full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
DRIVER INFORMATION Date of Birth Enter driver’s birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter year in which the driver was first licensed.
DRIVER INFORMATION Driver’s License Number/Soc. Sec. # Enter complete driver’s license number. If a license number is unavailable, enter the driver’s social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each listed driver (MM/DD/YYYY).
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
EQUIPMENT ACORD 129 Attached Use this section to summarize information on the trucks and tractors used by the applicant. Individual specifics on each truck or tractor should be completed in the Vehicle Section, ACORD 129. List the number of vehicles falling into each category.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Other Vehicle Type
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Other Vehicle Type Use this space to identify vehicle type not listed above.
EQUIPMENT Company Owned Specify the number of vehicles, per type, owned by the applicant.
EQUIPMENT Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant.
EQUIPMENT Long Term Leased Specify the number of long termed leased vehicles operated by the applicant.
EQUIPMENT Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month.
EQUIPMENT Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies’ manual rules.
EQUIPMENT Territory/Zone Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.
EQUIPMENT Total Company Owned Vehicles Indicate the total number of vehicles.
EQUIPMENT Total Non Owned Vehicles Indicate the total number of vehicles.
EQUIPMENT Total Long Term Lease Vehicles Indicate the total number of vehicles.
EQUIPMENT Total Trip Lease Vehicles Indicate the total number of vehicles.
GENERAL INFORMATION Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 1. Is there a vehicle maintenance program in operation? Explain type of program and if maintenance records are kept on file.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 2. Does the applicant obtain MVR verifications on drivers? Indicate if applicant reviews MVRs on all assigned drivers and how often. Indicate if review is upon hiring only. If No, provide explanation as to why MVRs are not reviewed.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 3. Does the applicant have a driver recruiting method? Describe the recruiting method. Indicate if written and/or road tests are conducted.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 4. Are any drivers not covered by Workers Compensation? Provide the names of all drivers not covered.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 5. Does applicant own or operate equipment not listed here? List all equipment not to be covered and explain why. Indicate where coverage is placed for this equipment.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 6. Does applicant haul any dangerous, caustic, radioactive or flammable cargo? Specify the type of cargo hauled, the percentage of business involved in this cargo and the estimated annual revenue derived from hauling this cargo.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 7. Does applicant haul target commodities? Indicate if the applicant hauls any property subject to high incidence of theft. Specify the type of cargo hauled, the percentage of business involved in this cargo and the estimated annual revenue derived from hauling this cargo.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 8. Do drivers receive a regular physical? List the frequency of the physical examinations. Example: annual or semi-annual.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 9. Does applicant hire equipment from others? List the source and kind of equipment.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 10. Does applicant rent or lease vehicles or equipment to others with / without operators? List the vehicles or equipment, drivers name (if any), and who is carrying the primary coverage.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 11. Does applicant haul for other truckers? Identify the work done for others and the percentage of estimated annual revenue involved in working for others.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 12. Do other truckers operate under the permit of the applicant? Specify the percentage of the total number of vehicles operated by others under the permit of the applicant.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 13. Is coverage required for travel in Canada or Mexico? List countries where coverage is required.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION 14. Are drivers compensated per trip? Indicate how the drivers are paid: per trip, by mile, by salary, or by contract. Give terms of agreement for remuneration.
GENERAL INFORMATION Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
GENERAL INFORMATION (continued) 15. Any Hold Harmless agreements? If any are in effect, state the provisions or attach a copy of the agreement.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 16. Any drivers with convictions for moving traffic violations? Give driver number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company’s and state’s requirements. In Kansas, certain traffic violations are not required to be reported to insurers.
GENERAL INFORMATION (continued) Drv # Enter the driver number referenced in the DRIVER INFORMATION section.
GENERAL INFORMATION (continued) Date (MM/DD/YYYY) Enter the date (DD/MM/YYYY) of the conviction.
GENERAL INFORMATION (continued) Type Enter the type of moving traffic violation.
GENERAL INFORMATION (continued) Place Enter the city and state where the conviction occurred.
GENERAL INFORMATION (continued) # Yrs Rev Enter the number of years reviewed, in accordance with the company’s and state’s requirements.
GENERAL INFORMATION (continued) 17. Do any vehicles have special equipment mounted or attached? Indicate which vehicles have been altered, customized or equipped with special equipment.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 18. Does applicant pull double or triple trailers? If yes, describe the operations, including the percentage of vehicles in each category.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 19. Does applicant have tow trucks or perform towing? Indicate how many tow trucks are owned or used by the applicant and describe towing operations.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 20. Are vehicles left unlocked when unattended? If yes, describe how vehicles and contents are protected from unauthorized entry.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 21. Are any overage, shortage or damage claims pending? If yes, describe, and provide dollar amounts.
GENERAL INFORMATION (continued) Remarks Use the space provided below each question to provide additional information for any questions answered with a “Yes” response. Use the REMARKS section if more space is required.
GENERAL INFORMATION (continued) 22. Are all vehicles to be included in this policy part of a fleet? Enter Y for a “YES” response. Enter N for a “NO” response.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an ACORD 45.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Additional Insured Indicate all appropriate options for the individual named.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Loss Payee Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Lienholder Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Employee as Lessor Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Other Interest Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Describe Other Interest Describe the other interest.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Rank Primarily used for Mortgagees – indicate the ranking such as 1st, 2nd or 3rd mortgagee.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Name and Address List the additional interests name and address.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Certificate Required If a Certificate of Insurance is required check this box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Vehicle List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Scheduled Item Number List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Other Item List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Describe Other Item Describe the other item.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Item Description If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Additional Insured Indicate all appropriate options for the individual named.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Loss Payee Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Lienholder Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Employee as Lessor Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Other Interest Check the applicable box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Describe Other Interest Describe the other interest.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Rank Primarily used for Mortgagees – indicate the ranking such as 1st, 2nd or 3rd mortgagee.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Name and Address List the additional interests name and address.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Certificate Required If a Certificate of Insurance is required check this box.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Vehicle List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Scheduled Item Number List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Other Item List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Describe Other Item Describe the other item.
ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Item Description If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting.
REMARKS Use this section to provide any additional information required for the underwriting or rating of this risk.