19. List below all drivers employed as of the proposed effective date: No. of Date Driver’s List Past Three Date of Driver’s Name of License State Driving Years of Accidents & Hire Birth No. Similar Traffic Violations Vehicle INSURANCE AND LOSS HISTORY 20. Have you had any insurance canceled, declined or non-renewed or filed bankruptcy in the last three years? (Not applicable in Missouri) Yes No If yes, explain: 21. Provide loss history for prior five years: No. of Liability Phys. Dam. Policy Prior Policy No. Of Units Losses Losses Losses Period Carrier No. Losses Insured Paid/Open Paid/Open Paid/Open OPERATION HISTORY 22. Provide prior three years, current and projected business history: Year Receipts Mileage Number of Power Units Current Year Projected for Coming Year SCHEDULE OF COVERED AUTOS 23. Provide autos to be scheduled on policy: Make/ Owner’s Trailer No. Year VIN No. (17 Digits) GVW/GCW Stated Value Radius Name Type* $ $ $ $ *Trailer Types: Car Carrier-CC, Container-CO, Dump Belly-DB, Dump End-DE, Flat Bed-FB, Hopper/Grain-HP, Livestock-LV, Log-LG Mobile/Modular Homes-MH, Tank, Dry Bulk/Pneumatic-TD, Tank, Liquid-TL, Van, Dry-VD, Van, Reefer-VR
19. List below all drivers employed as of the proposed effective date: Driver’s Name Date of Birth Driver’s License No. State No. of Driving Similar Vehicle Date of Hire List Past Three Years of Accidents & Traffic Violations INSURANCE AND LOSS HISTORY 20. Have you had any insurance canceled, declined or non-renewed or filed bankruptcy in the last three years? (Not applicable in Missouri) Yes No If yes, explain: 21. Provide loss history for prior five years: Policy Period Prior Carrier Policy No. No. of Units Insured No. Of Losses Liability Losses Paid/Open Phys. Dam. Losses Paid/Open Losses Paid/Open OPERATION HISTORY 22. Provide prior three years, current and projected business history: Year Receipts Mileage Number of Power Units Current Year Projected for Coming Year SCHEDULE OF COVERED AUTOS 23. Provide autos to be scheduled on policy: No. Year Make/ VIN No. (17 Digits) GVW/GCW Stated Value Radius Owner’s Name Trailer Type* $ $ $ $ *Trailer Types: Car Carrier-CC, Container-CO, Dump Belly-DB, Dump End-DE, Flat Bed-FB, Hopper/Grain-HP, Livestock-LV, Log-LG Mobile/Modular Homes-MH, Tank, Dry Bulk/Pneumatic-TD, Tank, Liquid-TL, Van, Dry-VD, Van, Reefer-VR
National%20Casualty%20Motor%20Carrier%20Appl.docx