Motor Truck Cargo

Application

 
  Interstate Indemnity Company

  Interstate Fire & Casualty Company

  Chicago Insurance Company

 

Answer all questions; attach separate sheet if necessary.  If any questions are not applicable, please indicate.

 

General Information

Applicant Name

Street or P.O. Box                                                                                             Apt.

City                                                                              State                            Zip

Home Phone #                                                              

Work Phone #

Applicant is                   a.     Common Carrier             b.     Contract Carrier

                                    c.     Owner of Property          d.     Other                                                                          

If Applicant is a.or b., give gross receipts for the past 12 months:   $                                                

Policy Term:  From                    to                                

Years in Business                                                           

Radius                          miles.                          

Average length of haul                miles.

What major cities will be traveled?  From                         to                        .  List any other major cities.

 

Gross Receipts Reporting Form desired?                     Yes                          No

Principal commodities carried and % of each:

 

 

Are any of the following hauled?  Check if so.

    Eggs                         Meat, Fish, Poultry                 Alcoholic Beverages                  Drugs

    Tobacco                    Rubber Tires, Tubes                Explosives                                Red Label Cargo

    Furs                          Petroleum Products                Textiles or Clothing                    Refrigerated Goods

    Livestock                   Fragile Articles                       Target Merchandise                   TVs Stereos

    Guns                         Perishables

Previous Carrier                                                                

Annual Premium $                                            

Policy No.                                                                    

Term:                            to                                

Did Company cancel or refuse to renew?                      Yes                          No

If yes, give reason.

 

Does Interstate Insurance Group write any coverage for this Insured?  Is so, list policy numbers.

 

Financial status:                 Good                  Fair                  Marginal                 Not analyzed (for gross receipts coverage, an up-to-date Financial Statement is required).

Type of Coverage and Limits

Coverage:   Named Perils     All Risk      Theft   Refrigeration Breakdown    Other                                  

 

Maximum limit per vehicle  $                                              

Limit any one catastrophe  $

 

Deductible per vehicle  $                                       

Average value of load  $

Description of Vehicles and Amounts of Insurance

 

Unit No.

Model Year

Trade Name

Truck, Tractor, Semi-Trailer, Full Trailer

Cargo Hauled

Model Series & Complete VIN Number

Max. Gross Wt. Of Vehicle (lbs.)

Max. Load Cap. In lbs., gals., liquids

Locks, Alarms

Amount of Insurance

 

 

1

 

 

 

 

Mod #:

 

 

 

 

 

 

VIN #:

 

 

2

 

 

 

 

Mod #:

 

 

 

 

 

 

VIN #:

 

 

3

 

 

 

 

Mod #:

 

 

 

 

 

 

VIN #:

 

 

4

 

 

 

 

Mod #:

 

 

 

 

 

 

VIN #:

 

 

5

 

 

 

 

Mod #:

 

 

 

 

 

 

VIN #:

 

 

Motor Carrier Filings

Filings required                   ICC                     State; Specifically name each state in which applicant operates.

 

ICC Docket Number

Drivers (M.V.R.s are required for all drivers)