RLI Transportation 2970 Clairmont Rd., Suite 1000 Atlanta, GA 30329 A division of RLI Insurance Company P: 404-315-9515 F: 404-315-6558 www.rlitransportation.com NON-FLEET TRUCKING APPLICATION NEW VENTURE (1 to 2 Power Units) Application Information: Insured s Name: Address 1: Address 2: City/State/Zip: Country: Extension: 800: Fax: Proposed Effective Date: Website: Proposed Expiration Date: Date Quote Required: Producer Information: Agency Name: Address 1: Address 2: City/State/Zip: Country: Website: Producer Name: Producer Number: Extension: 800: Fax: Are you the incumbent broker? If Yes, for how long?: Expiring Premium: Page 1 of 6
CSR Information: Name: Extension: Applicant Details: Applicant Type: Operation: MC Number: Employer Fed. ID: Number of Power Units: Is Owner/Operator? Name of Parent Company: Years in Business: Current management has controlled risk since: Garaging Location: Contact Person: Fax: Coverage Requested: Primary Liability Personal Injury Statutory Minimum UM Statutory Minimum UIM Statutory Minimum Physical Damage General Liability Cargo Liability Trailer Interchange Monthly Average Interchange Days Number Of Trailer Interchanged Per Month per Trailer Page 2 of 6
Commodities Hauled: Commodities % of Revenue Hazardous Average Value Maximum Value % at Max Total Loss History (attach separate sheet if necessary) Prior Carrier Effective Date Expiration Date Auto Liab. Losses GL Losses Comp/Coll Losses Cargo Losses Total No Of Losses Exposure History and Projections: Exposure History and Projections for Current Policy Year Total mileage for the current policy year: Trucking revenue for the current policy year: Number of Units: Exposure History and Projections for Upcoming Policy Year Total mileage for the upcoming policy year: Trucking revenue for the upcoming policy year: Number of Units: Equipment Information List all tractors and trailers (include values if physical damage coverage is to be provided). Co. Owned or Owner/Op? Unit Type Model Year Make Model GVW Vin # Stated Amount * Type = for power unit -- tractor, straight truck, service vehicle, other (describe). for trailers -- van, reefer, flat bed, auto hauler, dry tank, other (describe). Page 3 of 6
Mileage by State: (Enter projections for upcoming policy year or provide IFTA reports for most recent 4 quarters) State Mileage State Mileage State Mileage State Mileage State Mileage AL: ID: MI: NY: TN: AZ: IL: MN: NC: TX: AR: IN: MS: ND: UT: CA: IA: MO: OH: VT: CO: KS: MT: OK: VA: CT: KY: NE: OR: WA: DE: LA: NV: PA: WV: DC: ME: NH: RI: WI: FL: MD: NJ: SC: WY: GA: MA: NM: SD: AK: Driver List: (Attach current copy of each driver s MVR) Driver s Name Date of Birth License # State Years of CDL Experience Date of Hire # of Moving Violations & Accidents in the Past 3 years Miscellaneous Questions: 1. Has the applicant s insurance been declined, nonrenewal, or cancelled in the past 5 years? If so, provide reason(s): 2. Does the applicant act as a truck broker? If yes, is brokerage operation a separate corporation? Name of brokerage entity: (Note: RLI does not cover Non-Fleets acting as brokers.) 3. Does the applicant operate any other vehicles not listed? 4. Are placards ever required for any vehicle? 5. Are all trailers equipped with anti-lock brakes? Explain any Yes answers given above: 6. List all states where filings are required: Page 4 of 6
Additional Comments/Questions: Employment History: Prior Employer Start Date End Date Position Operation/Commodity Hauled List of Routes: From State To State List of Most Common Cities Hauled to: City State Do you have any contract to haul in place? List of Shippers: Page 5 of 6
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, Virginia and Washington, insurance benefits may also be denied. The applicant hereby applied 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. SIGNATURE INFORMATION: I accept the above mentioned terms and conditions. Signature Date City Where Signed Signed By Title of Signatory If a partnership or corporation, signatory must be empowered by Articles of Incorporation, et al, to bind insurance agreements. Page 6 of 6