A21 Commercial Auto
Customer Information
Was an interview conducted?
*
Yes
No
{"Yes":["3","4","6"]}
Person interviewed (Must be first and last name):
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Position and/or title?
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-- Please Select--
Owner
Bookkeeper
Manager
Assistant Manager
Tenant
Other
{" Other":["5"]}
What was the other title?
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What date was the interview conducted?
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Year
Commercial Auto
Check the box if you need to correct the address:
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Incorrect
{"Incorrect":["9","10","11"]}
Corrected Address
How did you obtain the corrected address?
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Address:
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Street address
Street address 2
City
State / Province
zip code
General Information
What type of business operations?
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-- Please Select--
Adult daycare center hauling
Archaeologist
Auto transport
Commodities transportation (Farm hauling)
Concrete hauling
Crop spraying
Drayage
Hauls used clothing
Heavy equipment hauling
Hot shot delivery
Long haul trucking
Meals on Wheels
Medical transport
Miscellaneous hauling
Oilfield equipment hauling
Oilfield services
Other
Short haul trucking
Sign making
Trucking company
Describe in detail the business operations.
*
Owners, Partners, and Officers:
How many owners/partners/officers?
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-- Please Select--
1
2
3
4
5
6
{"1":["17","18","19","21"]," 2":["17","21","19","18","25","24","23","22"]," 3":["17","18","19","21","22","23","24","25","29","28","27","26"]," 4":["17","21","19","18","22","23","24","25","29","28","27","26","33","32","31","30"]," 5":["17","21","19","18","25","24","23","22","29","28","27","26","33","32","31","30","37","36","35","34"]," 6":["17","21","19","18","25","24","23","22","29","28","27","26","33","32","31","30","37","36","35","34","41","40","39","38"]}
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
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-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
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25 years
Over 25 years
Active in the business?
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Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
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11 years
12 years
13 years
14 years
15 years
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25 years
Over 25 years
Active in the business?
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Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
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11 years
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13 years
14 years
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25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
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11 years
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13 years
14 years
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25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
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17 years
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19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Name:
*
Title:
*
Owner
Partner
Officer
Years of experience:
*
-- Please Select--
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
Over 25 years
Active in the business?
*
Yes
No
Vehicle Information
Did you get photos of some or all the vehicle and/or trailers insured?
*
Yes
No
{" No":["44"]}
Explain why you weren't able to obtain photos of the vehicles and/or trailers.
*
What is the total number of insured units including trucks and/or trailers?
*
Did you verify the attached vehicle list on the order with the insured?
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Yes
No
{"Yes":["47"]," No":["48"]}
Were there any additional vehicles that need to be added?
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Yes
No
{"Yes":["114","115"]}
Did you attach a vehicle list?
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Yes
No
{" No":["115","114"]}
Do they operate passenger cars in the business?
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Yes
No
Do they operate single axle truck/tractors in the business?
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Yes
No
Do they operate tandem axle truck/tractors in the business?
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Yes
No
Do they operate trailer/semi-trailers in the businesses?
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Yes
No
Where are the vehicles stored at night?
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Who performs maintenance/repairs on the vehicles?
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Own staff/Employees
Dealership
Outside independent garage
{"Own staff/Employees":["55","56"]}
Name of person responsible for the maintenance:
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Title:
*
Are maintenance records kept?
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Yes
No
Is there a formal safety program?
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Yes
No
{"Yes":["59","60"]}
Name of person responsible:
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Title:
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Do they have an accident investigation program in place?
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Yes
No
Do they have a substance abuse program in place?
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Yes
No
Operation Information
What is the radius of operations?
*
-- Please Select--
Locally only
100 miles
200 miles
300 miles
400 miles
500 miles
750 miles
1000 miles
1500 miles
2000 miles
Continental USA
What type of goods/products do they haul?
*
Are all loads transported properly secured?
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Yes
No
Does not apply
{"Yes":["67"]}
Describe in detail how loads are secured (Chains, straps, tarps, etc.):
*
Is hauling done for only one firm/company?
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Yes
No
{"Yes":["69"]}
Name of the firm/company:
*
Driver Information
Did you verify the attached drivers list on the order with the insured?
*
Yes
No
{"Yes":["72"]," No":["73"]}
Were there any additional drivers that need to be added or do you need to add a new list of drivers?
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Yes
No
{"Yes":["83","82"]}
Did you attach a drivers list?
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Yes
No
{" No":["83","82"]}
Do they use owner operators?
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Yes
No
Do they have any drivers under 18 years of age or over 65 years of age?
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Yes
No
Do they obtain MVRs on all new hires and owner operators?
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Yes
No
Do they obtain MVRs annually on all drivers and owner operators?
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Yes
No
Is there a policy in place to review MVR data?
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Yes
No
Has there been any losses in the past 5 years?
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Yes
No
{"Yes":["80"]}
Describe the losses.
*
Additional Notes:
*
Driver List
How many drivers?
*
-- Please Select--
1
2
3
4
5
6
7
8
9
10
{"1":["84","85","86"]," 2":["84","85","86","87","88","89"]," 3":["84","85","86","87","88","89","90","91","92"]," 4":["84","85","86","87","88","89","90","91","92","93","94","95"]," 5":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98"]," 6":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98","99","100","101"]," 7":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98","99","100","101","102","103","104"]," 8":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98","99","100","101","102","103","104","105","106","107"]," 9":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98","99","100","101","102","103","104","105","106","107","108","109","110"]," 10":["84","85","86","87","88","89","90","91","92","93","94","95","96","97","98","99","100","101","102","103","104","105","106","107","108","109","110","111","112","113"]}
Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
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Driver License #:
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Driver Name:
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Driver Age (In years):
*
Driver License #:
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Driver Name:
*
Driver Age (In years):
*
Driver License #:
*
Vehicle List
How many vehicles?
*
-- Please Select--
1
2
3
4
5
6
7
8
9
10
{"1":["116","117","118","119","120"]," 2":["116","117","118","119","120","121","122","123","124","125"]," 3":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130"]," 4":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135"]," 5":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140"]," 6":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140","141","142","143","144","145"]," 7":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140","141","142","143","144","145","146","147","148","149","150"]," 8":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140","141","142","143","144","145","146","147","148","149","150","151","152","153","154","155"]," 9":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140","141","142","143","144","145","146","147","148","149","150","151","152","153","154","155","156","157","158","159","160"]," 10":["116","117","118","119","120","121","122","123","124","125","126","127","128","129","130","131","132","133","134","135","136","137","138","139","140","141","142","143","144","145","146","147","148","149","150","151","152","153","154","155","156","157","158","159","160","161","162","163","164","165"]}
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