Towing Operations -BR- "*" indicates required fields Step 1 of 12 8% Full Name and "DBA" (if applicable)*Please include your Full Name and Business Name if applicable. Business Type* Individual/Sole Proprietorship Partnership Corporation LLC Other Select which type of business you are setup as.DOT NumberFEINPhone*Email* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is the Garaging Address the same as the Mailing?* Yes No Business Location (Garaging Address)* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Your Mailing and Business Location may be the same. Person to contact for inspection (name and phone number)* Description of operationsDescribe your business operations.*Please give us a good description of your business. Are you only providing Towing Services? Is repair, dismantling/salvage or repossession apart of your business? Any sales of vehicles or body work?Years in Business*Are you a new venture?* Yes No Are you a new venture in the trucking industry? This also includes setting up a brand new DOT. Five largest clients for which you provide towing services.(including police, commercial and auto clubs e.g. AAA)1*2*3*4*5* Add RemoveIs towing done for these entities under contract? Yes No Do you use any telematices, GPS or tracking devices on your vehicles? If so, who is the manufacturer?*Are you performing any repossessions?* Yes No Voluntary Yes No Involuntary Yes No How many Voluntary repossessions are performed each month?How many Involutary repossessions are performed each month?Is there a Formal Safety Program in place?*If yes, how many meetings held monthly? Who conducts the meetings? A copy of the Written Safety Program will be required if one is present. Is there a written Vehicle Maintenace Program in place?* Yes No Please describe your vehicle maintenance program.Any vehicles leased, loaned or rented to others?* Yes No Any ICC Filings required?* Yes No Any PUC Filings?* Yes No If Yes, please include the Name and Address below.IS MCS 90 Required? Yes No Dealer Plates #*Dealer ID #'s*Are Dealer Plates permanently attached to any vehicle?*If yes, please include a description of the vehicle and denote any personal use of the plates. Radius of Operations (Miles)*What Cities are you operating in?*How may times montly do you go beyond 50 Miles?*How many times monthly do you go beyond 200 Miles?*Do you pick up customers' cars other than towing?* Upload a driver list here.* Drop files here or Select files Max. file size: 98 MB. Please include the following with the list. Years of CDL experience Date of hire Number of accidents and/or moving violations in the last five years.Vehicle sectionSchedule of vehiclesPlease include the following for each truck or tractor. Year, make, model and type (truck, tractor, trailer, etc.) VIN number, Gross vehicle weight (GVW) and Annual mileage per vehicle. Vehicle 1*Vehicle 2Vehicle 3Vehicle 4Vehicle 5Please upload list of vehicles here if easier. Drop files here or Select files Max. file size: 98 MB. Please include date purchased, cost when purchased, any permanently attached equipment to be covered, and total stated amount to be insured for for each unit. Loss sectionHave you had any losses in the last 3 (three) years?* Yes No If yes, please explain the lossMake sure to include the date, amount paid and description of the loss. Pleas attach your 3 Year Loss Runs from your prior carrier here. Drop files here or Select files Max. file size: 98 MB. Please include loss runs for each carrier over the last 3 years. Filing InformationIs an FHWA filing required?* Yes No If yes, what is your MC number?FHWA Common carrier Contract carrier Broker Do you require FHWA cargo filings? Yes No If you are an interstate regulated carrier, identify your registration or base state.What state is your home base state and you are filed out of?Is an intrastate filing needed?* Yes No If yes, show state and permit number. Also list states for which you need cargo filings if any.Will our policy cover all vehicles owned, operated or under lease to your company?* Yes No If no, please explain why? Have you ever changed your operating name?* Yes No Have you changed names? Have you owned another trucking company in the past? Do you operate under any other names?* Yes No If yes, what other names?Do you operate as a subsidiary of another company?* Yes No Do you own or manage any other transportation operations that are not covered?* Yes No Do you lease your authority?* Yes No Have you purchased, sold or applied for authority over the past 3 years?* Yes No Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.) ?* Yes No Please explain any "yes" answer to the filing section above. Total Number of Employees*This may also include any Clerical Employees that are not drivers. Employee Payroll*Annual Payroll of all Employees. Annual Gross Receipts*Is your Property Fenced?* Yes No If yes to the above.What is the Height of the Fence and is it locked at Night?Watchman, Alarm, Lighting?*Please describe if any Watchman Service is used. Is an Alarm present? Is the area Well-Lighted?Any Dogs on Premises?* Yes No If answering Yes to the above.What Breed(s)? Are they Trained Guard Dogs? Are "Beware of Dog" Signs posted? Are dogs confined during business hours?Hours*What Days and Hours is the Business open?Storage*Please describe for whom and under what circumstances vehicles are stored. Who is your current insurance company?*How much do you pay annually?What is the total insurance cost currently you are paying with your current company?Attached a copy of your current insurance and any renewals you have from your current insurance company. Drop files here or Select files Max. file size: 98 MB. Consent* I agree to the following:No coverage is bound until the company advises the applicant or its representative that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges taht the Applicant's representative named below is acting as applicant's agnet and not on behalf of the company. The applicant's representative has no authority to bind coverage, may not accept any funds for the company, and may not modify or interpet the terms of the policy. The applicant agrees that the foregoing statements and answers are true and correct. The applicant request the company to rely on its statements and answers in issuing any policy or subsequent renewal. The applicant agrees that if its statements and answers are materially false, the company may rescind any policy or subsequent renewal it may issue. If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be attached to the policy which increases theCompany's liability, theApplicant agrees to reimburse theCompany in accordance with the terms of that endorsement. The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any othermatter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect. The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation. The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).Please include any information you believe relevant in helping to obtain the best pricing. 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