National Casualty Company 5615 W. 95th Street Scottsdale Insurance Company Oak Lawn, IL 60453 Scottsdale Indemnity Company 708-423-2350 Fax: 708-425-5077 Scottsdale Surplus Insurance Company Buschbach Insuranc Agency, Inc. CARRIER APPLICATION Name of Applicant: Agent Name: D/B/A: Producer: Mailing Address: Phone No.*: Address: Garaging Address: (if different than mailing) Agent No.: *Required on Fleets to assist Loss Control Phone Number: DOT No.: PLEASE ANSWER ALL QUESTIONS Loss Control contact name and telephone number: E-mail Address: Insured Website: PROPOSED EFFECTIVE DATE: From: To: 12:01 A.M., Standard Time, at the address of the applicant. DESCRIPTION OF OPERATIONS 1. Applicant is: Individual Partnership Corporation LLC Other: 2. How long has this operation been in business? Years trucking management experience: 3. Any other business currently owned or operated by the insured currently or in the past five years? Yes No If yes, provide name and description of operations: 4. Has there been any change in operations, ownership, management, or name during the last five years? Yes No If yes, provide details: 5. Radius of operations: 0-100 mi. % 101-300 mi. % 301-500 mi. % Over 500 mi. % If more than 500 approximately what percent of your miles will you travel to or through these four regional zones: ZONE 2: AZ, CO, IA, ID, IL, ZONE 3: AL, AR, FL, GA, ZONE 4: CT, DE, MA, ZONE 1: CA, NV, IN, KS, MI, MN, MO, MT, ND, KY, LA, MS, NC, OK, PA, MD, ME, NH, NJ, OR, WA NE, NM, OH, SD, UT, WI, WY SC, TN, TX, VA, WV NY, RI, VT % % % % 6. Are filings required? Yes No If yes, provide list: 7. Are any vehicles owned, operated or leased that are not included in the vehicle schedule? Yes No If yes, provide details:
National Casualty Company Scottsdale Insurance Company Scottsdale Indemnity Company Scottsdale Surplus Insurance Company Buschbach Insuranc Agency, Inc. 5615 W. 95th Street Oak Lawn, IL 60453 708-423-2350 Fax: 708-425-5077 CARRIER APPLICATION Name of Applicant: D/B/A: Mailing Address: Garaging Address: (if different than mailing) Phone Number: DOT No.: Loss Control contact name and telephone number: E-mail Address: Insured Website: Agent Name: Producer: Phone No.*: Address: Agent No.: *Required on Fleets to assist Loss Control PLEASE ANSWER ALL QUESTIONS PROPOSED EFFECTIVE DATE: From: To: 12:01 A.M., Standard Time, at the address of the applicant. DESCRIPTION OF OPERATIONS 1. Applicant is: Individual Partnership Corporation LLC Other: 2. How long has this operation been in business? Years trucking management experience: 3. Any other business currently owned or operated by the insured currently or in the past five years? Yes No If yes, provide name and description of operations: 4. Has there been any change in operations, ownership, management, or name during the last five years? Yes No If yes, provide details: 5. Radius of operations: 0-100 mi. % 101-300 mi. % 301-500 mi. % Over 500 mi. % If more than 500 approximately what percent of your miles will you travel to or through these four regional zones: ZONE 1: CA, NV, OR, WA ZONE 2: AZ, CO, IA, ID, IL, IN, KS, MI, MN, MO, MT, ND, NE, NM, OH, SD, UT, WI, WY ZONE 3: AL, AR, FL, GA, KY, LA, MS, NC, OK, PA, SC, TN, TX, VA, WV ZONE 4: CT, DE, MA, MD, ME, NH, NJ, NY, RI, VT % % % % 6. Are filings required? Yes No If yes, provide list: 7. Are any vehicles owned, operated or leased that are not included in the vehicle schedule? Yes No If yes, provide details:
National%20Casualty%20Motor%20Carrier%20Appl.docx