Commercial Automobile Insurance Application 1. Business Information: Business Name: * DBA: Business Type: * Individual Partnership Corporation LLC Other: Does the applicant have any subsidiary or sister companies?: * Yes No Physical Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Is the Mailing Address the same as the Physical Address? * Yes No Mailing Address: If different from physical address. Address 1 Address 2 City State/Province Zip/Postal Code Country Business Website: http:// Business Email: USDOT/MC #: 2. Coverages Primary Liability: 100 CSL 500 CSL 1MM CSL Uninsured Motorist: 100 CSL 500 CSL 1MM CSL Medical Payments: $5,000 $10,000 $15,000 Personal Injury Protection (PIP): $10,000 Yes No Physical Damage: Check ALL that apply: Comprehensive Collision Comprehensive Deductible: $500 $1000 $2500 Collision Deductible: $500 $1000 $2500 Broadened Pollution: Yes No Non Owned Auto: Yes No Hired Auto: Yes No Trailer Interchange: Yes No Cargo: Yes No Refrigeration Breakdown: Yes No N/A If YES, does the applicant interchange equipment with the subsidiary or sister company? Yes No If YES, name of all subsidiary or sister companies: Has the applicant filed bankruptcy in the past 7 years? * Yes No Number Does applicant or any affiliate act as freight-broker, fright-forwarder, of arrange loads for others? Yes No 3. Owner Operators If owner operators are used do they: Select ALL that apply: Participate in applicants safety program? Participate in applicants maintenance program? Sight permanent lease making them exclusive to the applicant? Have Non Trucking coverage? Does the applicant provide Workers' Compensation Insurance for employees? * Yes No Does the applicant require or provide Occupational Accident Insurance for Owner-Operators? * Yes No Does the applicant have General Liability coverage in place? * Yes No If YES, Please name carrier and limits: Does the applicant allow non-employee passengers? Yes No Is there any equipment permanently attached to the power units or trailers? Yes No If YES, please explain: Are all vehicles licensed for road use? Yes No If NO, please explain: Is there any personal use of scheduled autos? Select: Yes - 0-10% Yes - 11-20% Yes - 21-30% Yes - 31-40% Yes - 41-50% Yes - 51-60% Yes - 61-70% Yes - 71-80% Yes - 81-90% No/None 4. Safety Program & Features Does the applicant have a formal or informal safety program? Yes - Formal Yes - Informal No/Not Applicable If YES, check ALL that apply: Written Safety Policy Written Hiring Policy Driver Training - upon hire and recurrent Accident Review Policy Driver Incentive Program Documented Driver Vehicle Inspection Are vehicles equipped with any of the following? Select ALL that apply: Adaptive Cruise Control Speed Governors Lane Change Departure System On-Board Video Monitoring System Telematics (describe below) Other Active Safety Controls (describe below) 5. Hazardous Materials Does the applicant haul and hazardous materials? Yes No If YES, please check ALL that apply: The applicant is licensed to haul hazardous materials. The applicant has a written spill plan for drivers. The applicant delivers to rail yards, airports, or marinas. The applicant delivers directly onto trains, aircraft, or watercraft. Does the applicant provide all DOT hazardous materials training plus any refresher courses? Yes No Are drivers trained to assure liquids are unloaded into the proper tank? Yes No 6. Hired Auto Liability Complete only if Hired Auto Lability is requested. Does the applicant subhaul, lease or hire equipment from others? Yes No If YES, is the equipment permanently leased and scheduled on the policy? Yes No Does the applicant ever trip lease? Yes No Who provides the driver for leased/hired equipment? Applicant Equipment Owner Annual estimated cost of hire: 7. Hired Auto Physical Damage Complete only if Hired Auto Liability is requested. Does the applicant rent or use substitute equipment? Yes No 8. Nonowned Auto Complete only if Nonowned Auto is requested. Does the applicant authorize personal auto usage for business purposes? If YES, please explain: Does the applicant require proof of insurance? If YES, what are the minimum limits? 9. Completed By This Form Was Completed By: * By entering your name and clicking “Submit” you attest that you are an Officer and/or Employee of the requesting business/entity who has been granted full authority to transact business on the behalf of the above stated business/entity. Furthermore, you authorize East Coast Insurance Services, LLC and it's affiliates to obtain Insurance Quotes on your behalf. First Name Last Name Title: * Today's Date * MM DD YYYY Thank you, someone will be in contact within the next business day. We look forward to working with you!
