Quote Log Truck Insurance – Associated Loggers

1Company Profile

2Liability

3New Venture

4Driver Info.

5Vehicles & Trailers

6Losses

7Cargo

8Filings

9Wrap up

COMPANY PROFILE

Note, you must register and login to use this form. Also, you have 20 days to utilize the "save and continue later" special feature. All information your provide is confidential and encrypted for use by our staff and insurance underwriters. If you have questions please feel free to call us at 209 223-1870 and ask for Steve Valencia.

Business Name

If no DBA list Owner(s) name (s)

Business Entity Type

What legal formation does this business have?

What is your FEIN or Social Security Number

Please provide your employer identification number or (social security if an individual entity type)

Primary Contact Name

Primary Contact Phone Number

Primary Contact Email

Name of person completing this form

Phone

Primary Location Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the physical address the same as the Mail Address?

Yes

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Description of Operations

Years of experience

Is this your primary business?

Yes

What is your primary business?

Is the business seasonal?

Yes

Have you ever filed for bankruptcy?

Yes

When did you file for bankruptcy

Gross Receipts "last year"

Estimate Receipts for coming year

Do you operate in more than one State?

Yes

List all states you will operate in

Is the business for sale?

Yes

Do you haul "for hire?"

Yes

List the largest City entered

Do you operate over a regular route?

Yes

You answered yes. list towns operate between

Are you a common carrier?

Yes

Are you a Contract Hauler?

Yes

Who do you contract haul for?

List type of Cargo hauled

Do you haul any hazardous or extra hazardous substances or materials as defined by the EPA?

Yes

Provide complete listing identifying all material(s) and/or chemicals content

Do you haul your own cargo exclusively?

Yes

Who owns the cargo?

Do you haul doubles?

Yes

Do you haul triples?

Yes

Do you rent or lease your vehicles or trailers?

Yes

Upload a copy of the lease agreement

Accepted file types: jpg, pdf, Max. file size: 256 MB.

You may also fax a copy to 209 223-3227

Do you hire any vehicles?

Yes

Is this a new startup/ new venture?

Yes

New Venture Supplemental questions

Date New Venture Started

MM slash DD slash YYYY

Date and State you first received you Drivers License

MM slash DD slash YYYY

Who did you drive for prior to starting your own business?

What did you haul prior to becoming a new venture?

What is your primary route?

What will your future route be?

What and for whom will you be hauling?

Will the new venture require financing for this operatons?

Yes

With who will you be financing?

Are you applying for an ICC authority with Named Insured above?

Yes

When?

Who's Authority will you be using?

Do you expect to increase the number of vehicles within one year?

Yes

How many and when?

Describe your driver Hiring practes

Describe your vehicle maintenance program

Will you allow trip leasing?

Yes

Will you use team Driver?

Yes

Are Family members allowed to drive with you?

Yes

What are your anticipated gross yearly receipts?

What is your total estimated annual mileage?

Liability Limits - Select from the dropdown menu below

Carefully select your desired limits. There are split limits and Combined Single Limits (CSL)

Select Liability Limits

Driver List, Accidents & Violations

Add drivers by clicking on the "ADD ENTRY" button below

Name	DOB	Driver License #	Licensed in what State?	Yrs Lic	Experience Driving	No. Yrs. Commercial	Date Hired	# Accidents?	# "Major Convictions" in 10 Years?	Actions

There are no Entries.

Maximum number of entries reached.

You may add as many drivers as necessary by clicking on the "ADD ENTRY" button.

Vehicles & Trailers

Vehicles Trailers Physical Damage

Title	Year	Make & Model	Body Type	Full dentification #	GVW	# Rear Axles	Garage Location	Radius of Operations	Annual Mileage	Brakes	If leased, will lessor be added as "Additional Insured?	Lessors Address	Actions

There are no Entries.

Maximum number of entries reached.

Loss Experience

Have you had any claims in the last three years?

If yes, click on the "ADD ENTRY" button below

Yes

Disclose all losses in the last three years

From	To	Insurance Company Name	Number of Powered Vehicles	Number of Accidents	Are you aware of any facts or past incidents, circumstances or situatiions which could give rise to a claim under the insurance coverage sought n this application?	If yes to the question directly above, provide details	Have you ever been declined, cancelled or non-renewed for this kind of insurance?	Explain reason for cancellation for non-renewal	Actions

There are no Entries.

Maximum number of entries reached.

UPLOAD SECTION

Use this time to upload Driver motor vehicle reports, insurance history/claims records, photos of vehicles and other documents such as prior declarations pages. You may also fax information to 209 223-3227 or email to [email protected].

Upload claim File

Allowed file type. ".jpeg" and ".pdf" If you have other file formats email to [email protected] and be sure to include your company name and information in the email. Or, fax to 209 223-3227

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 256 MB, Max. files: 40.

Prior Insurance

Have you ever had insurance with any of the following Insurance Companies?

Check all that apply within the last five years

Acuity

American Forest Casualty Company RRG

Berkshire

National Fire & Marine Insurance Co

National Indemnity Co

National Indemnity Company of Mid America

National Indemnity Company of The South

National Liability & Fire Insurance Company

Progressive Insurance Company

Northland

OOIDA

Safeco

Sentry

Cargo

Your History with Cargo Coverage

Click on the "ADD ENTRY" button below

From	To	Company & Policy number	Premium	Number of Claims	Cause of loss	Amount Paid	Amount in Reserve if open claim	Actions

There are no Entries.

Maximum number of entries reached.

List type of cargo hauled

Describe Cargo Hauled	% of Hauling	Maximum Value	Average Value	Select Deductible	Actions

There are no Entries.

Maximum number of entries reached.

Select type of cargo coverage desired

Named Perils

Broad Form

Additional Coverage "OPTIONS"

Select Options

Additional Insured Endorsement - Lessee

Loading and unloading Coverage

Earned Freight Coverage

Refrigeration Breakdown Coverage

Hired Cargo Coverage

Exclude Theft Coverage

Filing Info.

Is an FHWA filing required?

Yes

What is your MC number?

Check all that apply

Common

Contracto

Broker

Do you Require FHWA cargo filing?

Yes

If you hold a Brokers license?

Yes

Idendify name filed with FHWA, FHWA docket no. and receipts from brokerage operations

Are you an interstate regulated carrier?

Yes

Identify your registration or base state

Is and intrastate filing needed?

Yes

For what State and provide permit number

Check all that apply

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Armed Forces Americas

Armed Forces Europe

Armed Forces Pacific

Show exact name and address(s) in which permits are issued

Is MCS 90 endorsement needed?

Yes

If issued, is our policy to cover all commercial vehicles & trailers

Yes

Explain your "no" response

Please explain why we are not covering all commercial vehicles and trailers?

Are oversized, overweight commodities hauled?

Yes

In what States are filing required for oversized loads?

Are escort vehicles towed on return trips ?

Yes

Does your authority allow for transportation of hazardous commodities?

Yes

Do you allow others to haul hazardous commodities under your authority?

Yes

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COMPANY PROFILE

New Venture Supplemental questions

Liability Limits - Select from the dropdown menu below

Driver List, Accidents & Violations

Vehicles & Trailers

Loss Experience

UPLOAD SECTION

Prior Insurance

Cargo

Additional Coverage "OPTIONS"

Filing Info.

More Underwriting Questions