INTERNATIONAL RISK PLACEMENT, INC.
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- Clarissa Lang
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1 1. Name of Applicant: 2. Address: 3. ICC Docket Number: 4. Number of Years in Business: 5. Broker bond Number or Bank Letter of Credit: 6. Types of Commodities Handled: 100% 7. How Many Loads Brokered In 2016:
2 PAGE TWO 8. Estimate Gross Receipts Forthcoming Year: 9. Past Three Years Gross Receipts: 2016/ / / Do you use other truck brokers to arrange movement of goods? If yes, how much: % 11. Do other truck brokers use you to arrange movement of goods? If yes, how much: % 12. In The Past Three Years Have You Been Named In A Suit: Explanation: 13. In The Past Three Years Have Any Claims Been Paid on Your Behalf Explain:
3 PAGE THREE 14. If New In Business, State Experience: 15. Limits please indicate which limit to be quoted: Contingent Automobile Liability a. $1,000,000 any one occurrence $1,000,000 annual aggregate b. $1,000,000 any one occurrence c. $2,000,000 any one occurrence d. $3,000,000 any one occurrence $3,000,000 annual aggregate e. $4,000,000 any one occurrence $4,000,000 annual aggregate f. $5,000,000 any one occurrence $5,000,000 annual aggregate Contingent Cargo Liability a. $100,000 per occurrence with a $1,000 deductible b. $250,000 per occurrence with a $1,000 deductible c. $500,000 per occurrence with a $1,000 deductible d. $100,000 per occurrence with a $1,000 deductible and Refrigeration Breakdown with deductible of $2,500 per occurrence e. $250,000 per occurrence with a $1,000 deductible and Refrigeration Breakdown with deductible of $2,500 per occurrence
4 CONTINGENT AUTOMOBILE LIABILITY, CONTINGENT CARGO LIABILITY, GENERAL LIABILITY, BUSINESS CONTENTS, TRUCK BROKERS ERRORS & OMISSIONS AND SEEPAGE AND POLLUTION BUYBACK APPLICATION PAGE FOUR General Liability a. $1,000,000 any one occurrence $1,000,000 annual aggregate b. $1,000,000 any one occurrence & annual aggregate Excess of $ 1,000,000 any one occurrence & annual aggregate c. $1,000,000 any one occurrence Business Contents a. b. $20,000 any one loss $50,000 any one loss Truck Brokers Errors & Omissions a. $100,000 any one loss b. $250,000 any one loss c. $500,000 any one loss d. $1,000,000 any one loss Seepage And Pollution Buyback For Contingent Automobile Liability a. $100,000 any one occurrence $200,000 annual aggregate
5 BUSINESS CONTENTS SUPPLEMENTAL APPLICATION PAGE FIVE 1. Details of the location address, if different to the mailing address. Please include the county. 2. What is the construction code of the building? 3. What is the age of the building? 4. What is the Protection Class? (this can be obtained from the local fire department) 5. How many stories is the building? Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Effective Date: Signature: THIS APPLICATION MUST BE RETURNED WITH SIGNED BROKERS CHECKLIST AND COPY OF BROKER AUTHORITY. THANK YOU.
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If YES, up to what dollar amount? $ 3. a. Average number of claims adjusted each year: b. Average dollar value of claims adjusted: $
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