TRUCK APPLICATION 1-10 Power Units

1 TRUCK APPLICATIONE ntire APPLICATION Must Be Completed and Signed1-10 Power UnitsGENERAL INFORMATIONNameIndividualCorporationPart nershipLLCO ther:Submission Number:Proposed Effective Dates: FROM:TO:Mailing AddressCityStateZIP CodeBusiness PhoneE-Mail AddressGaraging AddressCityStateZIP Code(if different)OWNER/PRINCIPALO wner Name (First, Middle, Last)Home AddressCityStateZIP CodeBusiness PhoneSS # of OwnerApt. #Tax ID: Federal ID # or SS # DOT #Yrs. Applicant has been Operating Under Business NameSafety Contact Person NameContact's PhoneSafety E-Mail AddressMC #DESCRIPTION OF OPERATIONSC ommodity (Check any that apply)For HirePrivateNon-TruckingOther:CommodityTy pe of Operation:Refuse/Waste/GarbageHazardous Materials requiring $1,000,000 Liability limits or lessHazardous Materials requiring Liability limits higher than $1,000, of LoadsMax.

2 ValueCommodity% of LoadsMax. ValueExplain:Not For HireRange of TransportOperations Less than 300 Mile Radius - List City Destinations BelowInterstateIntrastateOperations Beyond 300 Mile Radius - Identify Metropolitan Areas Traveled Through or IntoCities other than above or regular WorthDenverDetroitHartfordHoustonIndiana polisJacksonvilleKansas CityLittle RockLos PaulNashvilleNew OrleansNew York CityOklahoma CityOmahaOrlandoPhiladelphiaPhoenixPitts burghPortlandRichmondSt. LouisSalt Lake CitySan DiegoSan FranciscoSeattleTampaTulsaPercent of Loads:0 - 100 Miles101 - 300 Miles301 Miles +Longest Trip One Way:MilesNL-293 (4/12)Pageof 2012 The Travelers Indemnity Company.

3 All rights $$YesNoYesNoLocation(s)# UnitsAddress, City, filings required? If yes, complete Filing Information you act as a freight-broker or freight-forwarder or arrange loads for others? If yes, provide Brokerage Name:MC #Annual Brokerage all equipment operated under the applicant's authority scheduled on the APPLICATION ? no, attach % of loads brokered by you to all owned equipment scheduled on this APPLICATION ? If no, attach you lease your vehicles to others? If yes, who must provide primary liability coverage? other motor carriers or owner-operators haul for you?

4 If yes, complete questions below, complete Hired Autos APPLICATION Supplement and attach copy of lease agreement. If no, skip to question # on the Bill of what basis are they leased? annual cost of hire or # of vehicles leased with driver? leased vehicles included in this APPLICATION for insurance?(1)If yes, do you require leased vehicle owners to purchasenon-trucking liability coverage?(2)If there a written lease agreement stating the lessor willprovide primary auto liability coverage while leased to you? of Liability you secure evidence the lessor has primary auto liabilitycoverage?

5 The lease state that the lessor agrees to provide you with30 days advance notice if their insurance coverage is beingcancelled or reduced? you pull doubles? Triples? you haul intermodal containers? any portion of your operation seasonal? If yes, you use any team, hot seat, slip seating or relay driver operations? you allow passengers other than company employees? If yes, attach copy of passenger program or explain program (frequency, requirements), you operate more than one terminal? If yes, provide the following:PermanentBasisTemporary/Trip you sign contracts with shippers that give the shipper the right to determine cargo salvage values or declare cargos a total loss regardless of actual damage in the event of a loss?

6 If yes, attach a copy of the you operate mobile equipment subject to compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged? If yes, and need Liability Coverage, complete Mobile Equipment you require use of escort vehicles?If yes, and escort vehicles are not included in this APPLICATION for insurance, provide the name of the insurance carrier, policy number and auto liability yes and the escort vehicles are included in this APPLICATION , drivers of escort vehicles should be listed in the Driver information you haul over size, over weight loads?

7 If yes, attach (4/12)Pageof 2012 The Travelers Indemnity Company. All rights INFORMATION(Last, First, Middle)Date of BirthLicense NumberStateMust be Completed for All DriversDate of HireDriver Name# Yrs. DrivingSimilar N-3077 if additional space is needed for Driver Information, Insurance History, Schedule of Autos or Additional VIOLATION HISTORY - Past 3 Years(Last, First, Middle)Violations/Convictions#Driver NameAccidentsSpeedsOther Than Speeds# Minor# MajorsDate of Most RecentMoving Violation/Conviction# MinorDRIVER EMPLOYMENT HISTORYP rior Employment and Full AddressEmploymentof UnitDriver Name(Last, First, Middle)Dates ofTypeIf you have not had insurance for the past two years in your name, provide three years employment history for each driver.

8 (Use form TF-079 for additional drivers.) Do not indicate "self-employed" unless you have had insurance in your HIRING, TRAINING AND of the following is part of your driver screening/hiring process:Employment background checkPre-employment drug testCriminal background checkRoad testMotor vehicle record (MVR) reviewPre-employment Screening Program (PSP) Report from of the following is part of your driver performance management process:Annual review of driver's driving record (MVR)Review of electronic engine dataPeriodic review of driver and vehicle out-of serviceIncentives for violation-free and accident-free drivingviolations (SafeStat/CSA Reports)Formal corrective action proceduresPeriodic review of accidents/incidentsDriver safety you adhere to a written vehicle inspection and maintenance program?

9 If yes, describe or attach program:REVENUE AND MILEAGEPast 12 MonthsUnitsRevenue Per UnitNext 12 MonthsMileage Per UnitTotal RevenueTotal MileageINSURANCE HISTORY AND LOSS an insurance company cancelled or non renewed your policy in the last 3 years?(Missouri Applicants - Do not answer this question.)If yes, years insurance under business name with:Primary Auto Liability:Non-Trucking Auto other company name(s) you have operated under in the last 3 years:Company Names:Insurance Provider(s):NL-293 (4/12)Pageof 2012 The Travelers Indemnity Company. All rights Carrier NamePolicy Number# UnitsInsured#LossesPrior Carrier Effective DatesCoverageType* 3 years Prior Carrier Information.

10 Hard copy loss runs must be provided for risks with 5 or more Power Units .*Type: P=Phys. Dmg. C=Cargo L=Prim. Liab. N=Non-Trk. Liab. GL=Genl Liab. IM=Inland MarinetototoAccidentAmount of AccidentDescriptionDate ofLOSS HISTORY - Past 3 Years (including Drivers no longer employed)Driver Name(Last, First, Middle)SCHEDULE OF AUTOSAll Units you own or are leased to you must be scheduled and insured if filings are to be made. If you have more than 10 Power Units , form N-2379, Fleet APPLICATION , must be ensure Electronics (as defined by the policy), along with tarps, chains or binders are covered, include the value in each auto's stated VALUE COVERAGE - The Stated Limit of each auto must be equal to or greater than the outstanding financial obligation for that auto in order for the Financed Value Coverage to NumberUnit IDVehicle Type*Stated LimitGVW/GCWO wnership:MakeOwnedEmployee OwnedLeased Without DriverRadiusLeased w/ Driver Incl.