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 1-888-846-9965 Ext. 231.
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
 
OPERATIONS
 
PROPERTY HAULED
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?
DOCKET NO.
NUMBER OF EMPLOYEES
LIMIT OF LIABILITY
SINGLE CONVEYANCE PER DISASTER
$ $
DEDUCTIBLE
 
TERMINALS
 
LOC # ADDRESS AVG VALUE
AT TERMINAL
MAX VALUE
AT TERMINAL
LIMIT
OF LIABILITY
 
VEHICLES
# TRUCKS OPERATED # TRACTORS OPERATED # TRAILERS OPERATED # TANK-TRAILERS OPERATED # REFRIG. UNITS OPERATED
SPECIAL UNITS OWNED/OPERATED
VEH # MODEL
YEAR
VEHICLE TYPE ID #/
SER NO.
DATE
PURCHASED
NEW VEH
(CHECK IF "YES")
RADIUS
OF OPERATIONS
 
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
 
 REMARKS
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LOSSES
 
 LOSS HISTORY
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SOURCE
 
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