A21 Commercial Auto
Commercial Auto
Check box if you need to correct the address.
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Yes
{"Yes":["4","5","6","7"]}
Test 1
Corrected Address
How did you obtain the corrected address?
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Number and Street:
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City, State:
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Zip code:
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General Information
What is the radius of operations?
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-- 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?
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Are all loads transported properly secured?
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-- Please Select--
Yes
No
Dose not apply
Describe in detail how the loads are secured. (chains, straps, tarps, etc.)
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Is hauling done for only one firm/company?
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-- Please Select--
Yes
No
Name of the firm/company:
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Vehicle Information
Did you get photos of some or all the vehicle and/or trailers insured?
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-- Please Select--
Yes
No
What is the total number of insured units including trucks and/or trailers?
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Did you verify the attached vehicle list on the order with the insured?
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-- Please Select--
Yes
No
Do they operate passenger cars in the business?
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-- Please Select--
Yes
No
Do they operate single axle truck/tractors in the business?
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-- Please Select--
Yes
No
Do they operate tandem axle truck/tractors in the business?
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-- Please Select--
Yes
No
Do they operate trailer/semi-trailers in the businesses?
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-- Please Select--
Yes
No
Where are the vehicles stored at night?
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Who performs maintenance/repairs on the vehicles?
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-- Please Select--
Own Staff/Employees
Dealership
Outside Independent Garage
Are maintenance records kept?
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-- Please Select--
Yes
No
Is there a formal safety program?
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-- Please Select--
Yes
No
Do they have an accident investigation program in place?
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-- Please Select--
Yes
No
Do they have a substance abuse program in place?
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-- Please Select--
Yes
No
Driver Information
Did you verify the attached drivers list on the order with the insured?
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-- Please Select--
Yes
No
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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-- Please Select--
Yes
No
Did you attach a drivers list?
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-- Please Select--
Yes
No
Do they use owner operators:
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-- Please Select--
Yes
No
Do they have any drivers under 18 years of age or over 65 years of age?
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-- Please Select--
Yes
No
Do they obtain MVR's on all new hires and owner operators?
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-- Please Select--
Yes
No
Do they obtain MVR's annually on all drivers and owner operators?
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-- Please Select--
Yes
No
Is there a policy in place to review MVR data?
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-- Please Select--
Yes
No
Has there been any losses in the past 5 years?
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-- Please Select--
Yes
No
Describe the losses.
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Additional notes:
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Driver List
Driver Name:
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Driver Age:
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Driver License #:
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Driver Name:
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Driver Age:
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Driver License #:
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Do you have additional employees/drivers?
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-- Please Select--
Yes
No
Additional notes
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