TRUCK APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:
Applicant is:   Individual Corporation Partnership Other (Specify)
Garaging Location(s) if different:
Address:      City    State        Zip
Federal ID # or SSN U.S. DOT Number  
Yrs. in Trucking Industry Yrs. Operating in Your Name:   
DESCRIPTION OF OPERATIONS
For Hire Private Non-Trucking    Other (explain)    
Range of Transport Commodity (check all that apply)
Interstate
 Intrastate
  		Property (nonhazardous)      Refuse/Waste/Garbage
Hazardous Substances requiring $1,000,000 liability limits or less
Hazardous Substances requiring liability limits in excess of $1,000,000
        If checked, give explanation:
OPERATIONS LESS THAN 300 MILE RADIUS - List City Destinations
OPERATIONS BEYOND 300 MILE RADIUS: Identify Cities Traveled Through or Into
Atlanta
 Balt. – Wash.
 Boston
 Buffalo
 Charlotte
 Chicago
 Cincinnati		 Cleveland
 Dallas/Ft. Worth
 Denver
 Detroit
 Hartford
 Houston
 Indianapolis		 Jacksonville
 Kansas City
 Little Rock
 Los Angeles
 Louisville
 Memphis
 Miami		 Milwaukee
 Mpls./St. Paul
 Nashville
 New Orleans
 New York City
 Oklahoma City
 Omaha 		Philadelphia
 Phoenix
 Pittsburgh
 Portland
 Richmond
 St. Louis
 Salt Lake City		 San Diego
 San Francisco
 Seattle
 Tulsa
 Eastern Zone
 Gulf Zone
 Southeast Zone
  Other than above:
 
COMMODITIES TRANSPORTED
Commodity
Percent
of Loads
Maximum Value
Commodity
Percent
of Loads
Maximum Value
List shipper requirements, if any
Yes
No
  
1. Are filings required? If yes, complete form N-710, Filing Information.     Docket #
2. Do you act as a freight-broker or freight-forwarder or arrange loads for others?
    If yes, provide Brokerage Name:                                   Docket #
    Annual Brokerage Revenue $
3. Is all equipment operated under the applicant's authority scheduled on the application? If no, attach
    explanation.
4. Is all owned equipment scheduled on this application? If no, attach explanation.
5. Is all of the scheduled equipment owned by you? If no, attach explanation.
6. Do you lease or hire equipment from others? If yes, is it:
    a. If permanently leased, is it scheduled on this application?
    b. If permanently leased, are autos hired with drivers?
 Permanently Leased     Trip Leased
 Yes    No
Yes    No
    c. If trip leased, provide the annual estimated cost of hire: $
7. Do you lease to o thers? If yes, who must provide primary insurance? You   Other
    If you provide insurance, is coverage desired for: Named Lessee(s)    All Lessees (Blanket Basis)
    If Named Lessee(s), attach a list of Name and Address for each lessee.
8. Do you pull doubles?     Triples? Yes    No
 
DRIVER INFORMATION:  Must be completed for all drivers.  (Click "Add Drivers" for additional drivers)
Driver
Date of
Birth
License Number
State
# Yrs.
Driving
Similar
Equip.
Date of
Hire
Number Violations
#
Accid.
Last 3
Years
Past 3 Years
Past Yr.
#
Minor
#
Major
#
Minor
ADD DRIVERS

DRIVER EMPLOYMENT HISTORY  If you have not had insurance for the past two years in your name, provide three years employment history for each driver. (Click "Add Employment History" for additional drivers.) Do not indicate "self-employed" unless you have had insurance in your name.
Driver
Prior Employment & Full Address
Dates of Employment
Type of Unit
ADD EMPLOYMENT HISTORY

UNIT REVENUE & MILEAGE          Actual and Estimated
 
Period
Units
Revenue
Mileage
Projected
to
Current
to
INSURANCE HISTORY & LOSS EXPERIENCE   Number of years prior insurance:
(Click "Add Insurance History" for additional policy terms)
HAS ANY INSURANCE COMPANY CANCELED OR NONRENEWED YOUR POLICY IN THE LAST THREE YEARS?
Yes    No   If yes, explain:
POLICY HISTORY
LOSS HISTORY

Policy Term

InsuranceCompany

Policy No.

# Units
Insured

Any losses over the policy term?

#

Amount

Drivers
involved
in Loss
From
Mo/Yr
To
Mo/Yr
No Yes, then
$

No Yes, then

$

No Yes, then

$

ADD INSURANCE HISTORY

SCHEDULE OF AUTOS TO BE INSURED All units you own or are leased to you must be scheduled and insured if filings are to be made. If you have more than 10 power units, form N-2379, Fleet Application must be completed.
Click "Add Autos" if you want to schedule more than 3 autos.
No.
Model
Year
Trade Name
Type
Striped
Trailer
VIN
GVW
/GCW
Stated
Value
Max.
Radius
Owner's Name
1
Yes
 No
$
2
Yes
 No
$
3
Yes
 No
$
ADD AUTOS


FINANCED VALUE COVERAGE The Stated Value of each auto must be equal to or greater than the outstanding financial obligation for that auto in order for the Financed Value Coverage to apply.
LIENHOLDER INFORMATION - Click "Add Lienholder Information" to add lienolders.
Auto #
Name
Street Address
City
State
Zip Code
ADD LIENHOLDER INFORMATION


COVERAGES
AUTO LIABILITY            EMPLOYERS NONOWNERSHIP LIABILITY (# of employees )
LIABILITY FOR NONTRUCKING USE    Leased to:
LIMITS: Combined Single Limit (BI/PD) $ CSL
                Split Limits BI $ per person      $ per accident      PD $ each accident
HIRED AUTO LIABILITY
 DEDUCTIBLE REIMBURSEMENT LIMIT
Liability       Physical Damage      Cargo 		TRAILER INTERCHANGE (include copy of agreement)
Max  imum trailer value    # trailer days
PHYSICAL DAMAGE Deductible
Comprehensive OR $
Specified Perils $
Collision $
CARGO
    Limit $
    Deductible $
  Decline Hired Auto
 COMBINED DEDUCTIBLE
Coverage included unless declined.
Decline		 RENTAL REIMBURSEMENT
Select Units All Units
Amt. per day $
Days Coverage: 30 120
UNINSURED MOTORISTS
 Limits $
UNDERINSURED MOTORISTS Limits $
MEDICAL PAYMENTS
 Limits $
PERSONAL INJURY PROTECTION Limits $
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 send IFTA Reports as attachments to sales@yancyinsurance.com.

Application Completed By:        Title:       Date:

 

 

 


ADDITIONAL INFORMATION SUPPLEMENT

 DRIVER INFORMATION:  Must be completed for all drivers.
Driver
Date of
Birth
License Number
State
# Yrs.
Driving
Similar
Equip.
Date of
Hire
Number Violations
#
Accid.
Last 3
Years
Past 3 Years
Past Yr.
#
Minor
#
Major
#
Minor
Back to Application


DRIVER EMPLOYMENT HISTORY  If you have not had insurance for the past two years in your name, provide three years employment history for each driver. Do not indicate "self-employed" unless you have had insurance in your name.
Driver
Prior Employment & Full Address
Dates of Employment
Type of Unit
Back to Application

 

INSURANCE HISTORY & LOSS EXPERIENCE   Number of years prior insurance:
POLICY HISTORY
LOSS HISTORY

Policy Term

InsuranceCompany

Policy No.

# Units
Insured

Any losses over the policy term?

#

Amount

Drivers
involved
in Loss
From
Mo/Yr
To
Mo/Yr
No Yes, then
$
No Yes, then
$
No Yes, then
$
Back to Application

 

SCHEDULE OF AUTOS TO BE INSURED All units you own or are leased to you must be scheduled and insured if filings are to be made. If you have more than 10 power units, form N-2379, Fleet Application must be completed.
No.
Model
Year
Trade Name
Type
Striped
Trailer
VIN
GVW
/GCW
Stated
Value
Max.
Radius
Owner's Name
4
Yes
 No
$
5
Yes
 No
$
6
Yes
 No
$
7
Yes
 No
$
8
Yes
 No
$
9
Yes
 No
$
10
Yes
 No
$
11
Yes
 No
$
12
Yes
 No
$
13
Yes
 No
$
14
Yes
 No
$
15
Yes
 No
$
Back to Application


LIENHOLDER INFORMATION
Auto #
Name
Street Address
City
State
Zip Code
Back to Application