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 #