DRIVER HIRING, TRAINING AND SAFETY 1. Which of the following is part of your driver screening/hiring process: Employment background check  Criminal background check Pre-employment drug test   vehicle record (MVR) review  Road test  Pre-employment Screening Program (PSP) Report from FMCSA  2. Which of the following is part of your driver performance management process: Review of electronic vehicle driver performance data Annual review of driver’s driving record (MVR)   (telematics) Periodic review of driver and vehicle out-of service  violations (SMS/CSA Reports) Incentives for violation-free and accident-free driving  Periodic review of accidents/incidents Formal corrective action procedures   Driver safety training  3. Do you adhere to a written vehicle inspection and maintenance program? Yes No   If yes, describe or attach program. 4. How often do you replace your equipment? 5. Do you have any type of avoidance policies? Yes No   If yes, describe or attach policy. 6. Do you use any of the anti-theft devices to track equipment? Yes No   If yes, describe: 7. Do you have a Safety Director? Yes No   If yes: Full Time Part Time # Years with Company:    COVERAGES AUTO LIABILITY Limits: $ CSL  LIABILITY FOR NON-TRUCKING USE Limits: $ CSL  Leased to: EMPLOYERS NONOWNERSHIP LIABILITY Number of Employees  HIRED AUTO LIABILITY Cost of Hire  MEDICAL PAYMENTS Limits  REPORTING Revenue Mileage Units     DEDUCTIBLE REIMBURSEMENT Complete and Attach Supplement  TRAILER INTERCHANGE Provide a Copy of Agreement  # of Power Units Under Agreement: Maximum Trailer Value: # Trailer Days per Power Unit: PHYSICAL DAMAGE DEDUCTIBLES Comprehensive  OR Specified Causes of Loss Collision   HIRED AUTO PHYSICAL DAMAGE Complete and Attach Supplement  Limit Deductible CARGO OPTIONAL COVERAGES: (Check all that apply) Temperature Control Electronics Hired Auto Cargo    Aluminum, Copper Hard Liquor Cost of Hire:   Additional Earned Freight Increase Limit to $5,000 Pharmaceuticals   COMBINED DEDUCTIBLE Coverage included unless declined. RENTAL REIMBURSEMENT Selected Units OR All Units   Decline Combined Deductible Amount Per Day: Days of Coverage: 30 120    UNINSURED/UNDERINSURED MOTORIST AND OPTIONS Quoting Purposes Only – Uninsured Motorist Limits: Uninsured Motorist (Includes Underinsured Motorist) Limits: Personal Injury Protection Limits:
DRIVER HIRING, TRAINING AND SAFETY 1. Which of the following is part of your driver screening/hiring process:  Employment background check  Criminal background check  vehicle record (MVR) review  Pre-employment drug test  Road test  Pre-employment Screening Program (PSP) Report from FMCSA 2. Which of the following is part of your driver performance management process:  Annual review of driver’s driving record (MVR)  Periodic review of driver and vehicle out-of service violations (SMS/CSA Reports)  Periodic review of accidents/incidents  Review of electronic vehicle driver performance data (telematics)  Incentives for violation-free and accident-free driving  Formal corrective action procedures  Driver safety training 3. Do you adhere to a written vehicle inspection and maintenance program?  Yes  No If yes, describe or attach program. 4. How often do you replace your equipment? 5. Do you have any type of avoidance policies?  Yes  No If yes, describe or attach policy. 6. Do you use any of the anti-theft devices to track equipment?  Yes  No If yes, describe: 7. Do you have a Safety Director?  Yes  No  If yes:  Full Time  Part Time # Years with Company: COVERAGES  AUTO LIABILITY Limits: $ CSL  LIABILITY FOR NON-TRUCKING USE Limits: $ CSL Leased to:  EMPLOYERS NONOWNERSHIP LIABILITY Number of Employees  HIRED AUTO LIABILITY Cost of Hire  MEDICAL PAYMENTS Limits  REPORTING  Revenue  Mileage  Units  DEDUCTIBLE REIMBURSEMENT Complete and Attach Supplement  TRAILER INTERCHANGE Provide a Copy of Agreement # of Power Units Under Agreement: Maximum Trailer Value: # Trailer Days per Power Unit: PHYSICAL DAMAGE DEDUCTIBLES  Comprehensive  Collision OR  Specified Causes of Loss  HIRED AUTO PHYSICAL DAMAGE Complete and Attach Supplement CARGO Limit Deductible OPTIONAL COVERAGES: (Check all that apply)  Temperature Control  Electronics  Hired Auto Cargo  Aluminum, Copper  Hard Liquor Cost of Hire:  Additional Earned Freight Increase Limit to $5,000  Pharmaceuticals COMBINED DEDUCTIBLE Coverage included unless declined. RENTAL REIMBURSEMENT  Selected Units OR  All Units  Decline Combined Deductible Amount Per Day: Days of Coverage:  30  120 UNINSURED/UNDERINSURED MOTORIST AND OPTIONS – Quoting Purposes Only Uninsured Motorist Limits: Uninsured Motorist (Includes Underinsured Motorist) Limits: Personal Injury Protection Limits:
Northland%20Truck%20Fleet%20App.docx