FLEET APPLICATION 11 or More Power Units Entire Application Must Be Completed and Signed Submission Number: Proposed Effective Dates: FROM: TO: GENERAL INFORMATION  Individual  Corporation  Partnership  LLC Other  Name Mailing Address E-Mail Address Garaging Address (if different) Safety E-Mail Address Type of Operation:  For Hire  Not For Hire  Non-Trucking  Private Do you engage in operations other than trucking?  Yes  No If yes, explain: Has there been any change in the nature of operations, ownership, management or the name of the operation during the last five years?  Yes  No If yes, provide details: Range of Transport  Interstate  Intrastate Percent of Loads: 0 - 100 Miles 101 - 300 Miles 301 - 500 Miles 501 Miles + Longest Trip One Way: Miles OPERATIONS LESS THAN 300 MILE RADIUS - List City Destinations Below 1 2 3 4 OPERATIONS BEYOND 300 MILE RADIUS: Identify Metropolitan Areas Traveled Through Or Into Cities other than above or regular routes Percent of regular routes
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: