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NorthAmerican Transportation Association

Print & Complete form then Fax to: 310-337-7149

Account Executive Eva Gomez Date Time

NEED BY NEED BY PHONE #:

Date: Time: Contact: Fax #:

Primary Auto Non-Trucking Physical Damage Motor Truck Cargo General Liability (ACORD App.)

$750/$1,000,000 $750/$1,000,000 $500/$1000/$2500 $50/$100/$200/other $500/$1,000,000

1. Applicant:

FEIN/SS: Corporation Individual Partner Other:

2. Mailing address:

3. Garaging address:

4. Type of business: For Hire – Service – Courier – Retail – Personal – Tow – Other:

5. Permanently leased or contracted to:

Address: Phone:

6. Filings Required: FHWA: MC # Base State:

State(s):

Authority to Haul Hazardous Materials? Yes No Freight Brokerage Authority? Yes No

If Yes, attach Hazmat Supplement. If Yes, attach Brokerage Questionnaire.

Annual Gross Receipts: 1^st Year Prior: Next Year Projections

7. Is this a New Venture? Yes No If No, how many years in business under the above name:

8. Insurance History (3yrs, attach currently valued loss runs)

LIABILTY	Name of Carrier	Policy Number	Claims	Premium	Expiration Date
Current Year
1^st Prior Year
2^nd Prior Year
Physical Dam	Name of Carrier	Policy Number	Claims	Premium	Expiration Date
Current Year
1^st Prior Year
2^nd Prior Year
MTC	Name of Carrier	Policy Number	Claims	Premium	Expiration Date
Current Year
1^st Prior Year
2^nd Prior Year
GL	Name of Carrier	Policy Number	Claims	Premium	Expiration Date
Current Year
1^st Prior Year
2^nd Prior Year

Cancelled/Non-renewed? No Yes Why:

Claim Details:

7. If New Venture, need employer history. (5 yrs)

Employer: Hire Date: Termination Date: Address: Phone:

Employer: Hire Date: Termination Date: Address: Phone:

Employer: Hire Date: Termination Date: Address: Phone:

8. Commodities Hauled and % of each: % %

% % %

% % %

9. Cargo: Named Perils Named Perils & Theft Broad Form

Per Vehicle Limit: Deductible: Per Item Limit

Average Load: Maximum Load:

Additional Coverage’s

10. Radius Largest cities (pick up/drop off):

11. Mileage by State Running Total:

Include IFTA’s – 4 quarters and Schedule B with application if applicable.

AK	AL	AZ	AR
CA	CO	CT	DE
DC	FL	NFL	SFL
GA	ID	IL	IN
IA	KS	KY	LA
ME	MD	MA	MI
MN	MS	MO	MT
NE	NV	NH	NJ
NM	NY	NC	ND
OH	OK	OR	PA
RI	SC	SD	TN
TX	UT	VT	VA
WA	WV	WI	WY

12. Drivers: Name DOB D.O.H. Yrs. Exp. Driver’s License #

1.

2.

3.

4.

5.

13. Vehicles to be covered (Vehicles Inspection required on vehicles 10yrs or older)

If more than, 5 power units include: 3 year loss runs, balance sheet and income statement.

Year Make Body Type VIN# GVW/Gals Stated Amount

1.

2.

3.

4.

5.

14. Any non-owned vehicles/trailers? Double/Triple Trailers?

15. Hired Auto Liability: Cost of Hire