Do you maintain driver files as required by the DOT? yes no Are your trucks equipped with speed governors? yes no If yes, set at what speed? Are electronic log programs used to audit driver log books? yes no If yes, what program: Are your power units equipped with fender mirrors? yes no Does your safety program include safe driving incentive awards? yes no If yes, describe: Are units equipped with EOBR’s? yes no If yes, what features are activated? Current Insurer name: Policy deductibles: Current monthly reporting rates: Policy Number: Bodily injury: $ Mileage Revenue Power unit Policy Limits: $ Property damage: $ Liability monthly rate: $ Policy : Physical damage: $ Limits: $ from: / / to: / / COVERAGES Coverages available may vary by state and company Auto liability Liability for non-trucking use Limits - Combined single limit (BI/PD): $ Hired auto liability $ annual cost of hire Non-ownership liability Total number of employees: Are you required to coverage in excess of $1 million? yes no Trailer Interchange Maximum trailer value: $ Annual # trailer days: – Any additional insureds? yes no If yes, list the additional insureds and the interests of each: Physical Damage Cargo Combined Deductible Deductible Comprehensive or $ Limit $ Coverage included unless declined Specified Perils $ Deductible $ Declined Collision $ Declined Hired Auto Cargo Uninsured Motorist Limits $ Underinsured Motorist Limits $ Property Damage Liability Buyback (MI) Medical Payments Limits $ Personal Injury Protection Property Protection Coverage (MI PIP) Coverage selection/rejection form(s) for Uninsured Motorists, Underinsured Motorists, No-Fault, and Medical Payments insurance (as required by state law) must be completed and submitted together with this application for insurance coverage. Please provide state permit/authority numbers. Base state: Liability Cargo State Cargo State Liability Cargo State AL KY OK OCC # – AZ LA OR - not participating not participating – AR ME PA - Acord Cert Only not participating – CA EX # Intra State – MI SC CA - # Required MN SD CO MS TN
Do you maintain driver files as required by the DOT? yes no Are your trucks equipped with speed governors? yes no If yes, set at what speed? Are electronic log programs used to audit driver log books? yes no If yes, what program: Are your power units equipped with fender mirrors? yes no Does your safety program include safe driving incentive awards? yes no If yes, describe: Are units equipped with EOBR’s? yes no If yes, what features are activated? Current Insurer name: Policy Number: Policy Limits: $ Policy : from: / / to: / / Policy deductibles: Bodily injury: $ Property damage: $ Physical damage: $ Current monthly reporting rates: Mileage Revenue Power unit Liability monthly rate: $ Limits: $ Coverages available may vary by state and company Auto liability Liability for non-trucking use Limits - Combined single limit (BI/PD): $ Hired auto liability $ annual cost of hire Non-ownership liability Total number of employees: Are you required to coverage in excess of $1 million? yes no Trailer Interchange – Maximum trailer value: $ Annual # trailer days: Any additional insureds? yes no If yes, list the additional insureds and the interests of each: Physical Damage Cargo Combined Deductible Deductible Comprehensive or $ Specified Perils $ Collision $ Limit $ Deductible $ Declined Hired Auto Cargo Coverage included unless declined Declined Uninsured Motorist Limits $ Underinsured Motorist Limits $ Property Damage Liability Buyback (MI) Medical Payments Limits $ Personal Injury Protection Property Protection Coverage (MI PIP) Coverage selection/rejection form(s) for Uninsured Motorists, Underinsured Motorists, No-Fault, and Medical Payments insurance (as required by state law) must be completed and submitted together with this application for insurance coverage. Please provide state permit/authority numbers. Base state: Liability Cargo State Cargo State Liability Cargo State AL KY OK – OCC # AZ – not participating LA OR - not participating AR – Acord Cert Only ME PA - not participating CA – EX # Intra State MI SC CA - # Required MN SD CO MS TN COVERAGES
2016-IAT-Trucking-Fleet-Application.docx