MTC Application

MTC APPLICATION

Please fill out the form, and submit it to InsureCargo. For additional information or if you have any questions, please call Sales at 1-888-286-5647 Ext. 218.
CONTACT INFORMATION

NAME
YOUR RELATIONSHIP TO THE INSURED COMPANY

PHONE	FAX
EMAIL

INSURED COMPANY INFORMATION

COMPANY NAME
STREET ADDRESS 1
ADDRESS 2
CITY	STATE
COUNTRY	ZIP CODE
COMPANY WEBSITE
NO. OF YEARS IN BUSINESS

DOES THE APPLICANT HAUL ANY OF THE FOLLOWING COMMODITIES:
(CHECK IF "YES")		(CHECK IF "YES")
	FINE ARTS	FURS
	AIRCRAFT	LIQUOR
	AUTOMOBILES	WINE
	MOTORCYCLES	LIVE ANIMALS
	PLANTS	LOGS OR PULPWOOD
	WATERCRAFT	NEGOTIABLE INSTRUMENTS
	EXPLOSIVES	BULLION OR CURRENCY
	FIREARMS	REFUSE OR WASTE
	AMMUNITIONS	TOBACCO OR TOBACCO PRODUCTS
	CONTROLLED SUBSTANCES	DRUGS
	FLAMMABLE MATERIALS	PHARMACEUTICALS
	HAZARDOUS OR RADIOACTIVE CHEMICALS OR MATERIALS
	MOBILE HOMES OR PREFABRICATED BUILDINGS
	PRECIOUS METALS OR FINE JEWELRY

DOES THE APPLICANT OPERATE AS ANY OF THE FOLLOWING:
(CHECK IF "YES")		(CHECK IF "YES")
	FREIGHT FORWARDER	TRUCK BROKER
	BOAT HAULER	HOUSEHOLD GOODS MOVER
	TOW TRUCK OPERATOR	AUTO HAULER

HAS ANY DRIVER HAD ONE OR MORE OF THE FOLLOWING MOVING VIOLATIONS IN THE PAST 5 YEARS:
(CHECK IF "YES")
	ALCOHOL OR DRUG RELATED CONDITIONS
	REVOKED OR SUSPENDED LICENSE
	DUI OR RECKLESS DRIVING
	MORE THAN 4 MOVING VIOLATIONS

		LAST 12 MONTHS	NEXT 12 MONTHS
GROSS RECEIPTS

TERRITORY

AVERAGE DISTANCE

MAXIMUM DISTANCE

LIST STATES WHERE FILINGS ARE REQUIRED
I.C.C. FILING REQUIRED?	(CHECK IF "YES")
DOCKET NO.
NUMBER OF EMPLOYEES

DEDUCTIBLE

TERMINALS

VEHICLES

# TRUCKS OPERATED	# TRACTORS OPERATED	# TRAILERS OPERATED	# TANK-TRAILERS OPERATED	# REFRIG. UNITS OPERATED

SPECIAL UNITS OWNED/OPERATED

GENERAL INFORMATION

(CHECK IF "YES")
1	IS THE APPLICANT AN OWNER OPERATOR?
2	DOES THE APPLICANT HIRE OWNER OPERATORS?
3	DOES APPLICANT OBTAIN MVR VERIFICATION FOR DRIVERS?
4	DOES APPLICANT HAVE A DRIVER RECRUITING METHOD?
5	DO DRIVERS RECEIVE REGULAR PHYSICALS?
6	ARE VEHICLES EQUIPPED WITH THEFT ALARMS?
7	ARE VEHICLES LEFT UNLOCKED WHEN UNATTENDED?

* EXPLAIN ALL "YES" RESPONSES TO QUESTIONS 8 - 14 IN THE REMARKS SECTION

8	ARE VEHICLES LEFT LOADED OVERNIGHT?
9	IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?
10	ARE OVERAGE'S, SHORTAGES, & DAMAGE CLAIMS PENDING?
11	ARE ANY VEHICLES OPERATED FOR THE APPLICANT BY OTHERS?
12	HAS APPLICANT DECLARED BANKRUPTCY IN THE PAST 5 YEARS?
13	HAS APPLICANT'S INSURANCE BEEN CANCELED IN THE LAST 3 YEARS?
14	DOES APPLICANT AGREE TO BE RESPONSIBLE FOR LOADING OR UNLOADING OF GOODS AT THE SHIPPER'S OR CONSIGNEE'S PREMISES?

REMARKS

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LOSSES

LOSS HISTORY

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SOURCE

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