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                                                                TELL US ABOUT YOUR BROKERAGE
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NAME OF APPLICANT

ICC BROKERAGE MC #:

CONTACT NAME :

COMPLETE MAILING ADDRESS:

TELEPHONE #:            FAX #: 

EMAIL ADDRESS :

PROPOSED EFFECTIVE DATE:
 
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                                                       ABOUT  YOUR OPERATION
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COMMODITIES BROKERED:
 PLEASE BE SPECIFIC. TRY NOT TO USE THE TERM "GENERAL FREIGHT"

SO, IN OTHER WORDS, I AM BROKERING...(check all that apply)

DRY GOODS REFRIGERATED GOODS FLATBED FREIGHT TANKER PRODUCTS
HOUSEHOLD GOODS INTERMODAL CONTAINERS
 

 IF REFRIGERATED GOODS, WHAT PERCENTAGE OF TOTAL SHIPMENT?  %

ARE ANY OF THE COMMODITIES THAT YOU BROKER REQUIRED TO HAVE A PLACARD?
(hazardous waste)  SELECT ONE NO YES
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                                                      LIMIT OF INSURANCE DESIRED:
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A. Per trailer. group of trailers, motor truck or tractor: $100,000 MOST COMMON $250,000 $500,000
B. Per loss or casualty: $200,000 MOST COMMON $500,000 $1,000,000

DEDUCTIBLE AMOUNT DESIRED : $1,000 MINIMUM  $1,000 DEFAULT ON MINIMUM PREMIUM ACCOUNTS $2,500 $5,000

ANNUAL GROSS RECEIPTS   (If new authority, use N/A for previous years)

2 YEARS AGO:   1 YEAR AGO:

ESTIMATED PRESENT YEAR (Required)  SELECT ONE LESS THAN $300,000 $300,000 TO $500,000 $500,000 TO $1,000,000 $1,000,000 TO $2,000,000 $2,000,000 TO $5,000,000 $5,000,000 TO $10,000,000

                                                     

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                                                        MORE ABOUT YOUR OPERATION
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$100,000 $250,000 $500,000 CARGO LIMIT YOUR BROKERAGE REQUIRES OF TRUCKER (INSURED WILL BE
REQUIRED TO MONITOR AND CONFIRM THAT THE REQUESTED LIMIT IS IN FORCE FOR ALL
SHIPMENTS AND CONVEYANCES TRANSPORTED BY TRUCKERS THAT THIS INSURANCE WOULD BE CONTINGENT)

DO YOU SPECIALIZE IN ANY ONE TYPE OF MERCHANDISE?   NO YES
IF YES, DESCRIBE TYPE:

DO YOU PRIMARILY USE A PARTICULAR CARRIER? NO YES
IF YES, GIVE NAME OF CARRIER:

DO YOU OBTAIN CERTIFICATES OF INSURANCE FROM AUTHORIZED CARRIERS?  YES NO

IS THE LIMIT IF LIABILITY SHOWN ON THE MOTOR CARRIERS CERTIFICATE OF INSURANCE
ALWAYS EQUAL TO OR GREATER THAN THE SHIPMENT ASSIGNED TO THAT CARRIER? YES NO

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                                                              MORE ABOUT YOUR FREIGHT
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DO YOU ARRANGE SHIPMENTS FOR THE FOLLOWING?
 IF YES, WHAT PERCENTAGE OF TOTAL REVENUE?

AUTOS:        SELECT ONE NO YES    %                                      BOATS:  SELECT ONE NO YES    %
FURS:           SELECT ONE NO YES    %                                  JEWELRY:  SELECT ONE NO YES    % 
LIQUOR:      SELECT ONE NO YES    %                             MACHINERY: SELECT ONE NO YES    % 
PRODUCE:   SELECT ONE NO YES    %               PHARMACEUTICALS: SELECT ONE NO YES    %
SEAFOOD:   SELECT ONE NO YES    %                      SWINGING BEEF: SELECT ONE NO YES    % 
                      TOBACCO PRODUCTS: SELECT ONE NO YES    % 
ELECTRONICS(TV'S,VCR'S,STEREOS, ECT.): SELECT ONE NO YES   %  EXPLOSIVES: SELECT ONE NO YES   %

ARE YOU A MEMBER OF ANY PROFESSIONAL ORGANIZATION? SELECT ONE NO YES
IF YES, LIST ORGANIZATION(S):

WHAT IS YOUR PRIMARY GEOGRAPHIC TERRITORY (STATES)? 48 STATES EASTERN ZONE SOUTHEAST SOUTHWEST NORTHEAST NORTHWEST 11 WESTERN CENTRAL

ARE YOU RESPONSIBLE FOR ANY PACKING, LOADING OR UNLOADING? SELECT ONE NO YES

 

I hereby certify that the foregoing statements and answers are a just, full and true exposition of all the facts and circumstances with regard to the risk to be insured. Insofar as same are known to me, and the same are hereby made as the basis and condition of the insurance. Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false and deceptive statement may be guilty of insurance fraud and subject to fines and/or imprisonment. By signing below, I affirm full knowledge of and adherence to current FMCSA Regulations, and hereby apply for insurance with respect to the coverage stated herein.


                                                                           

                                                                       

                                                                  RESPONSE TIME

UNDER MOST NORMAL CIRCUMSTANCES, QUOTE ARE TURNED AROUND IN 24-28 HOURS.
ONCE YOUR QUOTE HAS BEEN RECEIVED, WE WILL ATTEMPT TO CONTACT YOU VIA PHONE, FAX, AND EMAIL.

                IF YOU DO NOT HAVE YOUR BOC-3 PROCESS AGENT FILING YET, GET IT HERE

                       IF YOU DO NOT HAVE YOUR 10,000 BOND IN PLACE, GET IT HERE