1. Applicant Name: 2. Garage Address: 3. Has the Insured had any cargo losses in the past 3 years? (Including the current term) YES/NO _____ 4. Does Insured haul any hazardous cargo? (fireworks, pyrotechnics firearms or weapons, petroleum gases, or related flammable or combustible substances - Refer to Section 5103 of the Federal Hazardous Materials Transportation) YES/ NO _____ 5. Does the insured use their personal private passenger vehicle to deliver solely for online retailers or on demand delivery services? YES/ NO ____ 6. Does the insured subcontract out for shipping more than 25% of their total receipts? YES/ NO _______ If yes, explain: _______________________________________________________ 7. Are the vehicles used to haul cargo on a formal maintenance program? YES/ NO _____ 8. Provide DOT (Department of Transportation) #: _____________ 9. Provide MC (Motor Cargo) #: _____________ (DOT number is for interstate travel, MC number is for in state. If the insured is doing both in state & interstate we will require both numbers.) 10. Commodities Carried: (If you don't see your commodity listed, please select the closes match & provide quick description) 11. Annual Cargo mileage: _____________ 12. Annual Gross Cargo receipts: ____________ 13. Enter the number of power units for the following types: Private Passenger vehicles: _________ Semi-tractors: _________ Box trucks or other commercial: ___________ 14. What is the insured's rating basis? (Subject to audit) Per mileage: ___________ Per gross receipts: __________ Per number of power units: __________ 15. Enter the percent of trips (between 0 and 100) for each of the following mile rangers. (The total must equal 100%.) 0-50 miles: ____ 51-300 miles: ____ 301-500 miles: ____ 501-1,500 miles: ____ Greater than 1,500 miles: ____ 16. Limit per vehicle? 17. Catastrophe (CAT) limit? 18. Any Cargo Filings required? Federal (Form BMC32/ BMC34) State (Form I/ Form H) 19. Provide MVR/ driver list (full name, driver license, DOB, any violations). 20. Will driver(s) leave vehicle unattended at any time? YES? NO ______ If yes, what are the safety measures taken? ommodities Carried: (If you don t see your commodity listed, please select the clo l C il Motor Truck Cargo Supplemental Application