American Underwriting Services, Inc

American Underwriting Services, Inc.. 2110 Powers Ferry Road NW Suite 303 Atlanta, GA 30339 Telephone: 770-874-0486 Fax: 770-874-0490

TRUCKERS APPLICATION Automobile Liability

Producer: Phone Number:

Fax Number:

Insured: *Attach a list of all subsidiaries or affiliated entities to be insured. For each entity, explain the relation to FEIN: applicant and describe operation(s). Also, attach a list of additional terminal locations and indicate number and type of units garaged at each. Mailing Address: Quote Date Effective Date

Individual Corporation Other How Many Years in Business? Partnership Joint Venture

Inspection:

Accounting Records:

Business: Common Carrier Contract Carrier Truck Broker Regular route Private Carrier Bobtail Operation Other Irregular route

ICC Filing Required: Yes_____ No *Applicant’s exact Name and Address as shown on ICC Authority. Filings may be rejected if not exact Docket Number: ICC# ______DOT #______.

Broker # if other than above______Is your name shown on bills of lading for loads you arrange for other truckers? ______

COVERAGE/LIMITS

COVERAGE LIMITS OF LIABILITY DEDUCTIBLE Per Accident Per Accident Liability none $ 1,000,000 $ 1,000 $ 2,500 $ 5,000 $ 10,000 $ 20,000 $ Other

Personal Injury Protection $ ______or Equivalent No-Fault $ ______Per Accident Coverage

Uninsured Motorists $ STAT

Underinsured Motorists $ STAT

Trailer Interchange Per trailer per accident $______Average limit $______Maximum limit $ ______# interchange days per year (total for all trailers) $ Hired Auto Liability States Cost of Hire

If Any

Non-Owned Autos States Number of Employees

If Any

Historical Exposures for Current and Prior 4 Years and Estimates for Upcoming Year POLICY PERIOD # REVENUE GENERATING UNITS REVENUE OR SALES MILEAGE DURING MONTH/YEAR TRUCKS TRACTORS DURING POLICY TERM POLICY TERM Proposed term Current term 1st Prior term 2nd Prior term 3rd Prior term 4th Prior term Equipment (Enter number of vehicles in each category) Include ALL units operating under applicant’s authority.

LEASED LEASED RADIUS (MILES) COMPANY TRIP VEHICLE TYPE WITHOUT WITH OWNED LEASED DRIVER DRIVER 0-50% 51-200% 201-500% 500+% Priv. Pass. Type Light Trucks Medium Trucks Heavy Trucks E-Heavy Trucks Tractors: Single rear axle Dual rear axle Other Total Power Trailers: Dry van Flatbed Dump Tank Refrigerated Containerized Other Total Trailers Other Total Vehicles

Commodities Transported – Include MSDS for any hazardous commodity.

COMMODITIES OUTBOUND % OF REVENUE COMMODITY BACKHAULED % OF REVENUE

NAMES OF PRINCIPAL SHIPPERS

LIST MAJOR METROPOLITAN CITIES HAVING MULTIPLE STOPS AND PERCENT OF OPERATIONS FOR EACH CITY

STATES WHERE ICC/PUC LIABILITY FILINGS ARE REQUIRED: (indicate with “x”) SHOW BASE STATE HERE: FL (Indicate for each state whether an intrastate (N) or interstate (I) filing is needed and show “T” # for California.) Alabama Missouri CANADA Alaska Montana Arizona Nebraska Alberta Arkansas Nevada British Columbia California New Hampshire Manitoba Colorado New Jersey New Brunswick Connecticut New Mexico Newfoundland Delaware New York Nova Scotia D.C. North Carolina Ontario Florida North Dakota P. E. Island Georgia Ohio Quebec Hawaii Oklahoma Saskatchewan Idaho Oregon Illinois Pennsylvania Indiana Rhode Island If other filings are required, please list below: Iowa South Carolina Kansas South Dakota Kentucky Tennessee Louisiana Texas Maine Utah Maryland Vermont Massachusetts Virginia Michigan Washington Minnesota West Virginia Mississippi Wisconsin Wyoming

GENERAL INFORMATION

1. DRIVERS YES NO COMMENTS Does applicant have a driver recruiting method? ______Have driver age requirements been established? ______Are all drivers covered by workers compensation? ______Do family members operate any vehicles? Include on driver list. ______Do drivers receive regular physicals? How often? ______Do drivers arrange their own backhauls? ______Are there any part-time employees? ______Do any employees have physical handicaps? ______Does applicant obtain MVRs at time of hire and semi-annually? ______Are completed applications required? ______Are road tests given? If yes, by whom? ______Does applicant check previous employment of drivers? ______Does applicant review driver records semi-annually? ______Are disciplinary records kept? ______Do drivers have at least 2 years experience for vehicle type? ______Is there a formal driver-training program in place? ______Are driver logs kept and reviewed? If yes, by whom? How often? ______Do all drivers have proper license for the vehicles they drive? ______Are certificates required and maintained? ______If vehicles are leased with drivers, what is the minimum limit ______required by applicant for non-trucking (bobtail) coverage? Are drivers paid per hour?______Based on revenue? xx______Mileage?_Yes_____ Per trip?______Are all drivers paid on ______the same compensation basis? EXPLAIN DIFFERENCES

2. MAINTENANCE Is there a garage facility for repair and maintenance of vehicles? ______Does applicant repair or maintain vehicles for owner/operators? ______Is there a formal vehicle maintenance program? ______Are maintenance files kept on owned vehicles? ______Are retreads used on power units?__NO_____ trailers?_yes______Are daily pre-trip and post-trip inspections made? ______Are maintenance files kept on leased vehicles? ______Are leased vehicles inspected? ______Do Shop Capabilities Include: ______Minor Repairs only? ______Major engine repairs? ______Major electrical repairs? ______Refrigeration equipment repairs? ______Brakes? ______Body work? ______

Explanations:

3. LOSS PREVENTION YES NO EXPLANATION

Is a formal safety program in operation? ______Are road patrols used? ______Are tachographs used? ______Does applicant investigate all accidents? ______Is there a Safety Director? ______Does the Safety Director perform other duties? ______Is there a safety award program? ______Are driver meetings held? If so, how often? ______What is applicant’s policy regarding passengers? If passengers ______are approved, is there passenger accident coverage in place?

4. GENERAL

Does applicant own or operate equipment not listed here? ______Does applicant haul any dangerous, caustic, radioactive or ______flammable cargo? Are all vehicles owned by and registered to the applicant? ______Are there any Hold Harmless Agreements? ______Does applicant hire drivers from school? ______Does applicant hire drivers from driver leasing firms? ______Does the applicant hire equipment from others? Does the applicant rent or lease vehicles or equipment to others ______with or without operators? Does applicant haul for other truckers? ______Do other truckers operate under the applicant’s permit? ______Does applicant utilize team drivers? If yes, show # of teams. ______Do any vehicles have special equipment? ______Are there any liquid storage tanks? ______Are there any hazardous wastes (oils, brake linings, etc.) which ______must be disposed of? Has any policy or coverage been declined, canceled or non- ______renewed during the past 3 years? What percent of tractors pull double trailers? ______What percent of tractors pull triple trailers? ______Describe any major changes (contracts, operating territories, management, etc.) in applicant’s operations during the last 5 years.

Describe any material changes anticipated in operations during the next 12 months.

Recap of Loss Experience - Include Minimum of Current and Prior 4 Years. Currently valued Insurance Company Loss Runs are to be provided. (Do not use “see attached” in this section.)

POLICY LOSSES PAID PERIOD LIABILITY DEDUCTIBLE # OF B.I. P.D. RESERVES TOTAL INSURANCE MO/YR LIMIT AMOUNT ACCIDENTS B.I. P.D. INCURRED COMPANY

Explain any accident which has an incurred loss (paid and/or reserved) over $50,000 in the past 5 years. Explain any accident that resulted in fatalities.

DATE OF AMOUNT AMOUNT TOTAL LOSS DESCRIPTION OF LOSS DRIVER’S NAME PAID RESERVED INCURRED

I/We declare that the above statements and particulars are true and that I/we have not omitted, suppressed or misstated any material facts and agree that this APPLICATION FORM shall be the basis of any policy of Insurance which may be issued by the Company and shall be deemed a part thereof.

It is agreed that the signature to the form does not bind the Company nor the applicant to complete insurance.

REQUIRED!

SIGNATURE TITLE DATE

Owner, Partner or Officer (Insured)

Producer (Agent)

Agent checklist: Completed and signed application. Currently valued (within the last 60 days) insurance company loss runs for the last 5 years. Driver schedule and current MVR for each driver scheduled. Our form is attached for your reference. Equipment schedule. Include all vehicles operating under the applicant’s authority. Our form is attached for your reference. If you use a different form, be sure to show all information requested on our schedule. Financial statement for the most recent full year to include a P & L and balance sheet. Schedule B from the most recent Fuel Tax Report. Copy of each type of lease agreement used. Copy of Hold Harmless agreements. Copy of applicant’s operating manual with hiring guidelines, disciplinary procedures, training program, and maintenance procedures, etc. Copy of the most recent DOT inspection with rating, if available.