Berkshire Hathaway Homestate Companies Specialty Auto Department

Transcription

1 Berkshire Hathaway Homestate Companies Specialty Auto Department Truckers Supplemental Application 3/10/05 Applicant Name: Effective Date: Address: Phone Number: General Questions: 1. Description of operations: 2. Years In Business: 3. Annual Gross Receipts last year: Estimate for coming year: 4. Have you ever filed for bankruptcy? Yes No If yes, when: Explain: 5. Prior Insurance Carrier, five previous years: (Please disregard if this is a renewal with BHHC) Year Carrier # of Vehicle Premium Losses Paid Current Reserves $ Involved in Litigation (Y / N) 6. Has your insurance ever lapsed, cancelled, or non-renewed? Yes No If yes, explain: Operations: 1. Do you haul for hire? Yes No 2. Type of carrier: Private Contract Common Exempt Household Goods Other 3. Do you operate in more than one state? Yes No If yes, list states: 4. List the largest cities into or through which vehicles are operated? Maximum radius of operations: Normal radius of operation: 6. Percent beyond normal operations: 7. Operating Territory: Percent City Percent rural Percent night 8. Routes: Regular Irregular 9. Do you require state and/or Federal filings? Yes No State filings, list states: ICC MC Docket # Base registration state Oversize / overweight filings 1

2 Other describe: 10. If you are ICC regulated please attach a copy of your Schedule B for each of the past three years: Attached Not Required 11. List all kinds and types of cargo hauled: 12. Do you require filings associated with the hauling of hazardous materials? Yes No If yes, specify: 13. Do you haul any hazardous or extra hazardous substances or material as defined by the EPA: Yes No If yes, give complete listing, naming material(s) and/or chemical content: 14. Do you have any exposure associated with the hauling of soil contaminated with fuel, fertilizer, chemicals, mine tailings, or any other hazardous material or waste? If yes, give complete details: 15. Have you ever had any prior exposure associated with the hauling of soil contaminated with fuel, fertilizer, chemicals, mine tailings, or other hazardous material or waste? If yes, give complete details and dates: 16. Do you haul any flammable or explosive material? Yes No If yes, give complete listing: 17. Do you haul any liquid material? Yes No If yes, please describe: 18. Do you haul any heavy and/or oversized equipment? Yes No If yes, give details: 19. Do you haul your own cargo exclusively? Yes No If not, who owns it: 20. Do you pull double trailers? Yes No Triple trailers? Yes No 21. Do you pull refrigerated units? Yes No If yes, describe and give details of cargo hauled? 22. Do your operations include any international or containerized hauling? Yes No 23. Do you hire any equipment? Yes No If yes, describe annual frequency: Annual cost of hire: 24. Do you lease or rent your equipment to others? Yes No If yes, describe: 25. Have you ever been in violation of Federal DOT regulations or requirements: Yes No If yes, explain: 26. Have you ever lost or had your authority withdrawn? Yes No 27. Have you been or are you under probation by any regulatory authorities? (ICC, PUC, etc.) Yes No 28. Are vehicle inspections performed regularly? Yes No By whom? 29. Are vehicles scheduled for regular maintenance? Yes No Who performs maintenance? Are maintenance logs maintained for all vehicles? Yes 30. Do you operate as a subsidiary of another company? Yes No If yes, provide name and describe: 31. Do you operate under any other name? Yes No If yes, please provide details: 2 No

3 32. Do you own or operate any power units not scheduled on this insurance policy? Yes No If yes, explain: (please indicate number of vehicles, body type and usage) 33. Have you ever changed your operating name? Yes No 34. Do you operate under any other name(s)? Yes No If yes, please provide name(s) and details: 35. Do any vehicles and/or agents not scheduled on this policy operate on your behalf? Yes No If yes, provide name(s) and details: 36. Do you use any owner operations? Yes No If yes, answer the following: A. Do you require signed 12 month agreements with cancellation provisions? Yes No B. How many units? C. Are they contracted 100% to account? Yes No D. Are Certificates of Insurance required? Yes No If no, is insured providing coverage? Yes No If yes, what is the minimum liability limit required? 37. Are you involved with trip leasing? Yes No If yes, answer the following: A. How many trips? B. Are Certificates of Insurance required? Yes No C. What is the minimum Liability Limit required? D. Are signed agreements in place? Yes No E. Does trip leaser use our Placard/DOT numbers in any way? Yes No 38. Are Vehicles stored at a single location? Yes No If yes, total maximum value of all vehicles at any one time: Driver Information: 1. Are all drivers your employees? Yes No If no, explain: 2. Are all drivers listed on the acord application for insurance? Yes No 3. Are all of your employees covered by Workers Compensation? Yes No 4. Do you agree to promptly report all newly hired drivers? Yes No 5. Do you order MVR s on all drivers prior to hiring? Yes No 6. Minimum years driving experience required: 7. How are drivers paid: Hourly Trip Mileage Other: 8. Drivers maximum driving hours: Daily Weekly 9. During the last 12 months, how many drivers were: Hired Fired Quit 3

4 10. Number of drivers employed by you: Years Employed 0-1 year 1-3 years 3-5 years 5+ years Number of Employees 11. Are drivers allowed to take vehicles home: Yes No Management Program: 1. Are passengers allowed to ride in company vehicles? Yes No 2. Are driver log audit procedures in place, effective, and verified? Yes No 3. Driver supervision include Awards Discipline program Safety incentives Safety meetings 4. Are accident reporting, investigation, review, and analysis programs in place? Yes No 5. Is a comprehensive security program in place with full management support? Yes No 6. Does employee selection include security concerns? Yes No 7. Do training programs include security training? Yes No 8. Security measures for transit, trailers parked in yard and cargo stored on the dock and warehouse include: Electronic monitoring Trailer locks Fence Empoyee background checks Controlled access Guards Building alarm systems Gates Other Motor Truck Cargo/Transit 1. Estimated average dollar value per load: 2. Estimated maximum dollar value per load: 3. Are hazardous materials properly handled, manifested, labeled, and placarded? Yes No N/A If yes, explain what materials are, etc.: 4. Cargo shipping documentation and record keeping system adequate for security purposes? Yes No 5. Describe procedures that are in place for proper loading and cargo securement to prevent load shifting and damage in transit: 6. Describe how perishable cargo is handled, packed and stored: 7. Is there a preventative maintenance program in place on all trailer refrigeration and/or heating units in order to protect perishable cargo? Yes No 4

5 If Workers Compensation coverage is provided, answer the followings: Manual Material Handling 1. Describe controls that are in place to help prevent employee injuries from manual material handling: 2. Describe how trailer and dock doors are designed and maintained to prevent injuries: 3. Additional Comments: Slips and Falls 1. Describe the training used to teach the three point procedure for getting in and out of trucks: 2. Describe the housekeeping policy emphasized at maintenance shops, warehouses, docks, terminals, and etc. for prevention of slips/trips/falls: 3. Additional Comments: Signature of Producer Signature of Insured 5