Malwa Financial & Insurance Agency
Effective Date:
Time:
Contact:
Fax #:
Primary Action Non-Tracking
Physical Damage
Cargo
General Liability (ACORD App.)
Applicant:
Proposed Effective Date:
Corporation
Individual
Partner
Other :
Commodities Hauled and % of each:
%
%
%
%
%
Radius:
From:
To:
Largest cities (pickup/drop off):
Drivers:
Name
Age
Date Hired
Yrs. Exp.
MVR Record
Vehicles to be covered and coverages requested:
Yr/Make/Model
Comp-SP-Coll,Deds
Cost New
GVW
Stated Amt.
Fillings Required :
FHWA :
MC #
Base State :
State(s) :
Authority to Haul Hazardous Materials?
Yes
No
Annual Gross Receipts :
Previous Carrier :
Canceled/Non-renewed
(N/A in MO)
? :
Yes
No
Why :
Target Pricing :
Loss History (3 years)
CARGO :
Named Perils
Named Perils& Theft
Broad Form
Per Vehicle Limit :
Dedectible :
Per ItemLimit :
Average Load :
Maximum Load :
Additional Coverages:
Agency
AGENCY #