LARGE FLEET TRUCKING APPLICATION CHECKLIST (50 or more Power Units)

Transcription

1 RLI Transportation 2970 Clairmont Rd., Suite 1000 Atlanta, GA A division of RLI Insurance Company P: F: LARGE FLEET TRUCKING APPLICATION CHECKLIST (50 or more Power Units) Insured s Name:_ Address: Insured s Expiration Date: Proposed Effective Date: Date Quote Requested: Agency: _ Agency Website: Agency Address: _ Producer Name: Producer CSR s: Ext: Phone: 800: Fax: _ Are you the incumbent broker: _ If Yes, for how long? To underwrite this application, the following materials must be provided and attached to this application: 1. Financial Statements: Balance sheets and income statements on an accrual basis for the last 2 fiscal year ends and a current interim statement (if the most recent year-end statements are more than 6 months old) are required. We prefer audited or reviewed statements, if available. Statements should include revenue obtained through trip lease and brokerage operations. Parent company financials, if applicable, should be provided. 2. Loss Runs: Provide documented loss experience, valued within the past 90 days from prior insurers for all lines of coverage requested for the current and 3 prior years. Please note that current year plus 5 prior years will be needed if coverage is requested in excess of $2 million. Provide details on all losses in excess of $50,000. Provide summary of losses on page 7 of this application. 3. Expiring Policy Premium: Provide expiring policy declaration pages for each coverage. Complete the expiring policy premium section on page 3 of this application. 4. Mileage: Provide fuel tax reports, indicating mileage by state and total mileage for all states for the previous 8 calendar quarters. Indicate any mileage which may not be included on fuel tax reports. Record mileage summaries and projections on page 2 of this application. 5. Revenue: Record revenue history and projections on page 2 of this application. Page 1 of 12

2 6. Equipment Schedule: Attach current listing of all company owned and owner/operator vehicles, including year, make, model, VIN, current market value, where garaged and licensed. For local/intermediate operations, (up to 300 mile radius) include gross vehicle weight for each unit. 7. Drivers List: Attach listing of all drivers operating equipment to be covered by this proposed insurance: company drivers, owner/operators, drivers of service and private passenger units. List should include full name of driver, date of birth, state of license issued, driver s license number, and date of hire. Copies of the most recent motor vehicle reports (MVRs) on file with the applicant are requested for all drivers. 8. Agreements: Provide copies of all applicable agreements used by applicant, including permanent lease, trip lease, holdharmless, interline, interchange, intermodal, and sub-hauler agreements. 9. Safety Materials: Attach copy of most recent state or federal compliance review and current compliance rating document. Provide copies of pertinent fleet safety and maintenance programs and materials. LARGE FLEET TRUCKING APPLICATION Insured s Name: (As it appears on all regulatory filings) MC #: Street Address: Mailing Address: _ Phone: 800: _ Fax: Name of Parent Company:_ Insured s Web-site: Structure: C Corp S Corp Partnership Proprietorship Employee ID #: Current Management has controlled risk since (year) and has been in the trucking business since _ (year). CORPORATE PERSONNEL % of % of Ownership Ownership President: Maintenance Manager: _ VP/Gen l. Mgr.: Safety/Risk Manager: CFO/Contoller: Inspection Contact(s): _ Key Contact Person:_ Title: Phone: Fax: _ List all Subsidiaries and Affiliated Companies and explain what they do and if they are to be included on the policy. Add attachment, if necessary. Company Type of Business Included on Policy? Yes Yes Yes OPERATIONS Type of Operation: % Truckload % Less than Truckload Page 2 of 12

3 Segments: _ % Dry Van _% Liquid Tank _% Other (describe) _ % Refrigerated _ % Dry Bulk _% Other (describe) _ % Flatbed _ % Containerized _% Other (describe) Radius of Operations (% of miles) Up to 100 % % % Over 500 % Average Length of Haul _ miles Maximum Length of Haul miles % of Deadhead miles % Do you haul doubles? Yes If Yes, % of total miles. Do you haul triples? Yes If Yes, % of total miles. Do you use driver teams? Yes If Yes, % of tractors seated with teams. EXPOSURE HISTORY & PROJECTIONS Period From Mo/Yr To Mo/Yr Mileage Revenue Avg. No. of Revenue Units Payroll Next 12 Mos. Current Year 1 Year Prior 2 Years Prior 3 Years Prior EXPIRING POLICY PRICING Coverage Total Premium by Coverage # of Power Units Premium per P.U. Auto Liability General Liability Cargo Owned Equipment Physical Damage Non-Trucking Auto Liability Page 3 of 12

4 Owner/Operator Physical Damage Trailer Interchange Other CARGO Commodities % of Revenue Hazardous? Average Value Maximum Value % at Max 1. _ 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10. Total = 100% Average values per trailer $ Maximum values per trailer $ Maximum terminal exposure $ Is cargo ever stored on dock or in terminal yard over 72 hours?... Yes If Yes, _% of time. Is cargo ever left unattended on the road?... Yes If Yes, unattended _% of time. Is standard Bill of Lading issued?... Yes If No, attach copy of form used. Do you haul under a full value bill of lading or a released value bill of lading? Full Value Released Value List your top 3 shippers and % of total revenue: Describe any specific cargo, including high hazard (hazardous, radioactive, waste materials) and high value: Page 4 of 12

5 EQUIPMENT INFORMATION (include values if physical damage coverage is to be provided; also attach equipment schedule) Vehicle Type Straight Trucks Road Tractors Yard Trucks Trailers Container Chassis Service Units Private Passenger Cars Other (describe) Co. Owned & Long Term Leased # $ Values Current 12 Months Owner/Operators # $ Values Projected Next 12 Months Co. Owned & Long Term Leased # $ Values Owner/Operators # $ Values Do you have any surplus equipment not presently being utilized? Yes If Yes, please explain: If the insured values for equipment to be covered for physical damage exceed $1,000,000 at any one location, provide: Location Avg. Values Max. Values % at Max. Location Avg. Values Max. Values % at Max Percentage of your equipment with anti-lock brakes: % Tractors % Trailers Do you utilize any of the following: Satellite/Tracking Equipment, Communication Devices, or Alarms?... Yes If Yes, describe: TERMINALS Location (City/State) # Vehicles Assigned Controlled Entrance? 24 Hr. Guard? Fenced? Lighted? For Local Intermediate risks (up to 300 miles radius), list the most frequent runs and approximate percent of total: From To % From To % Page 5 of 12

6 GENERAL Please answer the following questions. If you answer Yes to any question, please describe in the Explanations section below: Have you ever been cancelled or non-renewed within the last 5 years?... Yes Have you filed for bankruptcy protection within the last 5 years?... Yes Do you lease property, vehicles, or mobile equipment to others?... Yes Do you perform any rigging?... Yes Do you perform service or repair work on other than company-owned equipment?... Yes (Describe type of work performed, number of vehicles at any one time, revenue derived, and list any Garage Liability Insurance in-force: Insurer, Policy # and Term, Limits) Do you have any fuel storage facilities on your premises?... Yes (List products stored, capacity, and list any Pollution Liability Insurance in-force: Insurer, Policy # and Term, Limits) Do you sell any product on a wholesale or retail basis?... Yes Do you derive any revenue from warehousing?... Yes Do you allow passengers to accompany drivers?... Yes (If Yes, describe your policy, including authorization and frequency.) Explanations, if any: Please describe ANY MAJOR CHANGES in the applicant s operations over the last 5 years and planned for the next 2-3 yrs. Include growth/downsizing, commodities, customers, territories, equipment, driver hiring, personnel, financial, etc: TRIP LEASES Do you trip lease drivers & equipment from others to haul freight under your authority?... Yes If Yes, _% of revenue. Please explain how you locate your trip lessors and how you control the return of your placards: Do you inspect trip lessors equipment?... Yes Do you trip lease your drivers & equipment to others to haul freight under the other motor carrier s authority?... Yes If Yes, % of total revenue. Page 6 of 12

7 Do you require authorization to be granted to a driver before they may enter into a trip lease agreement?... Yes Please explain your controls: BROKERAGE Do you arrange for the transportation of property, by other motor carriers under the other carrier s authority?... Yes If Yes, identify motor carriers utilized: Name of your brokerage entity: Annualized revenue: $_ Licensed?... Yes MC # Are separate accounting records kept?... Yes Do you purchase contingent cargo coverage?... Yes Before brokering loads, do you require any of the following: Certificate of insurance?... Yes Limits required? $ Are certificates on file and up to date on all brokered loads?... Yes Additional Insured endorsements?... Yes Who is named on the Bill of Lading? Applicant -OR- Other Motor Carrier AGREEMENTS Are any Permanent Lease, Trip Lease, Hold-Harmless, Interline, Intermodal, Interchange, or Sub Hauler agreements in place? Yes (If Yes, attach copies.) TRAILER INTERCHANGE Is Trailer Interchange Legal Liability coverage requested?... Yes If Yes, please provide the following: Average number of trailers per day: Average number of days trailers are interchanged per month: _ Average value per trailer: $ Maximum value per trailer: $ TANK OPERATIONS Do you operate a tank wash facility?... Yes Is it operated as a separate entity?... Yes If Yes, name of entity? _ Is it insurance coverage requested?... Yes Do you wash tanks for others?... Yes If Yes, provide annualized revenue: $ Is hazardous waste generated from your tank wash?... Yes If Yes, explain disposal methods & carrier(s):_ Do you have any blending or storage operations?... Yes If Yes, provide annualized revenue: $ If Yes, list products blended or stored: Page 7 of 12

8 SAFETY & DRIVER HIRING Safety Director s tenure with applicant: Is Safety Director responsible for hiring?... Yes Years of safety experience: Percent of time devoted to safety: % Safety Director reports to: Name Title: Does Safety Director have the ultimate authority to hire and fire drivers?... Yes Current number of drivers:_ Employees:_ Owner/Operators: Sub haulers (CA only):_ Total: Drivers hired in past 12 months:_ Drivers replaced:_ Drivers added :_ Minimum driver age:_ Maximum driver age:_ Minimum commercial driving experience: Average Compensation (circle per mile or per year): Company Driver: $ Owner/Operator: $ How often do drivers return home? _ Are drivers unionized?... Yes Do your driver hiring procedures include: Written Application?... Yes Reference Checks?... Yes Road Test?... Yes Prior Employer Interviews?... Yes Physical Exam?... Yes Drug Testing?... Yes O/O Equipment Inspection?... Yes Written Test?... Yes MVR Review?... Yes Do you hire drivers from training schools?... Yes If Yes, describe your on-the-job training program for these drivers: Does your new driver training include: Equipment familiarization?... Yes Handling commodities?... Yes Route familiarization?... Yes Emergency procedures?... Yes Accident reporting procedure?... Yes Training required for owner/operators?... Yes New drivers assigned to a senior driver trainer?... Yes If Yes, how long will they drive together? Length of new driver training program? _ Additional comments on driver recruiting and training: MAINTENANCE Do you have a written maintenance program?... Yes If Yes, attach copy. Do you perform your own repairs... Yes Number of maintenance personnel: Are pre/post trip inspections performed?... Yes Define your inspection and preventative maintenance schedule intervals: A_ B C_ Are owner/operators equipment subject to the same maintenance requirements as company equipment?... Yes Page 8 of 12

9 Describe your plans to replace or upgrade your equipment: FILINGS List the states or Canadian provinces where applicant has Liability or Cargo Filings: Note: Before coverage can be bound, copies of all filings to be made must be received. LOSS EXPERIENCE SUMMARY Coverage Policy Dates Total $ Incurred Total # Incurred Deductible Limits Auto Liability to to to to General Liability to to to to Cargo to to to to Owned Equipment Physical Damage to to to to Non-Trucking Auto Liability to to to to Owner/Operator Physical Damage to to to to Page 9 of 12

10 Other to to to to Provide detail on all losses in excess of $50,000 (provide attachment, if necessary): COVERAGES REQUESTED Preferred Rating Basis (select one): Revenue Mileage Preferred Plan (select one): Deductible (DED) Self-Insured Retention (SIR) Coverage Auto Liability *Uninsured Motorists (UM) & * Underinsured Motorists (UIM) Option 1 Option 2 Option 3 Limit DED/SIR Limit DED/SIR Limit DED/SIR Excess Liability General Liability Cargo (per vehicle/per Occurrence) Physical Damage Owned Equip. Values = $_ Select: FTCAC or Comp Collision Page 10 of 12

11 Private Passenger Autos & Service Units: Auto Liability Physical Damage Values = $ Select: FTCAC or Comp Collision Trailer Interchange Owner/Operator Programs: Non-Trucking Auto Liability O/O Physical Damage Values = $ Select: FTCAC or Comp Collision Garage Liability Other: * (If Applicant rejects coverage where permitted and accepts minimum limits where rejection is not permissible, write REJ/MIN) * (If Applicant selects statutory minimum limits, write MIN) * (If Applicant selects policy limits or other limits, fill in limit requested) * Note: In order to bind coverage, applicant will need to sign appropriate UM/UIM rejection/selection forms. General Fraud Statement (Not applicable in Colorado, Nebraska, Ohio, Oklahoma, Oregon, Utah, and Vermont) Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and (NY: substantial) civil penalties. In the District of Columbia, Louisiana, Maine, Tennessee and Virginia, insurance benefits may also be denied. Page 11 of 12

12 The Applicant hereby applies to the Company for a policy of insurance as set forth in this application on the basis of statements contained herein. Applicant agrees that such policy shall be null and void if such information is materially false or misleading so that the Company would have rejected the risk prior to inception. Applicant understands that an inquiry may be made which will provide applicable information concerning character, general reputation, financial stability and other pertinent financial data, personal characteristics, mode of living or other background information the company deems necessary in order to determine whether the Company will accept or reject Applicant for coverage. Upon written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided. The Applicant understands this application is a request for quotation and no information provided herein shall be construed by either party as creating a binding contract for insurance. Signed this day of, at _ By For Name Title (If Named Insured is other than an individual) (If a partnership or corporation, signatory must be empowered by articles of Incorporation, et al, to bind insurance agreements.) Page 12 of 12