1. Page 1 of 5
Motor Truck Cargo Insurance
Application
Named Insured:
Mailing Address:
Policy period or date policy is to be in effect:
Business is: Corporation Partnership Sole Owner
Common Carrier Private Carrier Contract Carrier
Established in 19
For whom does trucker haul primarily?
Operates in state of:
With what regulatory commissions are cargo filings made?
ICC (include # ) States (include # )
Note: If not currently required by regulatory authorities, attach latest year-end statement.
Name of present insurance company:
Is present policy being cancelled or non-renewed
Present insuring conditions: All Risks Named Perils Theft
Deductible: $
Radius of operations (%) Local: % Intermediate %
Long Haul: %

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Equipment type
Number of
Pieces of
Equipment
Company
Owned
Long
Term Lease
Trip Lease
From Other
Drayage
Trucks
Tractors
Semi-Trailers
Full trailers
Tank Semi-trailers
Refrigerated Trailers
Is equipment leased, loaned or rented to others? Yes No
Does applicant interchange equipment with other carriers? Yes No
Details:
Gross receipts for the past two years: 19 19
Motor Carrier $ $ $
Freight forwarder $ $ $
Owner Operator $ $ $
Freight Broker $ $ $
Shippers Agent $ $ $
Other $ $ $
Warehousing $ $ $
Total $ $ $
Name principal commodities hauled (avoid term “General Commodities”)
Does applicant offer insurance coverage to shippers, beyond Bill of Lading?
Yes No
Provide details and annual values:
PREMIUMS AND LOSSES
Period Losses (Paid and Outstanding) Total
From To Prem Fire Collision Overturn Theft Other

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CARGO LIMITS REQUESTED
Cargo Limits Requested: $ per vehicle: $ per disaster $
Average exposure per vehicle: $ Maximum exposure $
Per vehicle: $
How long, on average, have drivers been with applicant?
Check as appropriate. If you have multiple locations, please attach responses for
each location.
TERMINALS WHERE VEHICLES MAY BE KEPT – attach a copy if required for
additional locations
Address Construction Protection Limit
$
$
$
Does applicant offer insurance coverage to owners, beyond warehouse receipt?
Yes No
Provide details and annual values:
Any other entities to be listed as
Additional Insureds?
Yes No
Name or Entity Provide details Interest/Activity
1.
2.
3.
4.

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BUILDINGS OR REAL PROPERTY TO BE INSURED – attach copy if required for
additional locations
Address Construction Protection Value
1. $
2. $
3. $
GENERAL INFORMATION – Explain all “YES” responses
1. Is there a vehicle
maintenance program in
operation? If yes, who
maintains the vehicles?
Yes No 9. Are vehicles
equipped with
anti-theft
devices? If yes,
describe
Yes No
2. Does applicant obtain MVR
verification before hiring
drivers?
Yes No 10. Are vehicles left
unlocked when
unattended?
Yes No
3. Does applicant have a driver
recruiting method?
Yes No 11. Are any vehicles
operated for the
applicant by
others?
Yes No
4. Does applicant have a driver
training method? If Yes, who
trains new drivers?
Yes No 12. Do terminals
have fire
protection?
Yes No
5. Does applicant have a loss
prevention program? If yes,
who runs the program?
Yes No 13. Do terminals
have guards or
watchmen? If
yes, how many
when closed?
Guard
Watchmen
6. Do drivers receive regular
physicals? If Yes, how often?
Yes No 14. Do terminals
have alarms,
fences, lights or
dogs?
Alarm
Fences
Lights
Dogs
7. Are drug tests performed at
the same time?
Yes No 15. Are vehicles left
loaded
overnight?
Yes No
8. Are two drivers used on high-
value shipments?
Yes No 16. Are loaded
vehicles brought
home by drivers?
Yes No
17. Does applicant
have a written
company
personnel
policy?
Yes No

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INSURED’S WARRANTY
I UNDERSTAND THAT THE INFORMATION CONTAINED ON THIS APPLICATION
IS CORRECT AND ACCURATE. ANY MATERIAL DISCREPANCIES MAY CAUSE
ANY SUBSEQUENTLY ISSUED POLICY TO BE AMENDED OR CANCELLED, AT
THE DISCREION OF UNDERWRITERS.
Insured’s Signature: Date:
Agent or Broker:
Address:
Agent or Broker Signature: Date: