← Back to Forms New Business Application You can start your application for insurance here. "*" indicates required fields 1Client Information2Contact & Business Information3General Operations4Auto5General Liability6Property7Warehouse / Cargo8Warehouse / Cargo (continued)9Warehouse / Cargo (continued)10Crime11Worker12Comments / Explanations Please complete any relevant sections of this application. Notice: This form requires Javascript to function correctly. If you are not able to enable Javascript, we recommend using the alternative PDF form. Client InformationFirst Named Insured* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Address FEIN* Effective Date* MM slash DD slash YYYY Years In Business*Please enter a number greater than or equal to 0. Contact & Business InformationFirst Named Insured Owner's Names & Titles*NameTitle% Ownership Add RemoveContact Name & Title* First Last Title Email Phone #*Van Line Affiliation Additional Named InsuredsAdditional Named InsuredsFEINDescription of OperationsOwner's Names & Titles% of Ownership Add RemoveRadius of OperationPlease provide a percentage of authority for each operation radius below. Fields should show a value between 0 - 100 and the total field must not exceed 100.Under 50 milesNeighborhood Authority Total (must equal 100%)% Your Authority*Please enter a number from 0 to 100.% Van Line Authority*Please enter a number from 0 to 100.% Other Authority*Please enter a number from 0 to 100.50 to 100 milesLocal Authority Total (must equal 100%)% Your Authority*Please enter a number from 0 to 100.% Van Line Authority*Please enter a number from 0 to 100.% Other Authority*Please enter a number from 0 to 100.101 to 300 milesIntermediate Authority Total (must equal 100%)% Your Authority*Please enter a number from 0 to 100.% Van Line Authority*Please enter a number from 0 to 100.% Other Authority*Please enter a number from 0 to 100.301 to 500 milesRegional Long Haul Authority Total (must equal 100%)% Your Authority*Please enter a number from 0 to 100.% Van Line Authority*Please enter a number from 0 to 100.% Other Authority*Please enter a number from 0 to 100.Over 500 milesCountry-wide Long Haul Total (must equal 100%)% Your Authority*Please enter a number from 0 to 100.% Van Line Authority*Please enter a number from 0 to 100.% Other Authority*Please enter a number from 0 to 100. General OperationsDoes your company act as a Freight Forwarder under your authority?* Yes No N/A Does your company conduct business other than Moving & Storage? (i.e. sell packing material, crating, manufacture boxes, self-storage, rigging, equipment rental, auto repair, PODS, shredding).* Yes No N/A Please provide a description of these operations and revenue of each.*If you are a Van Line Agent, are you required to provide primary auto liability insurance while operating under van line authority?* Yes No N/A Are any special certificates required?* Yes No N/A To whom?* Excluding Van Line, do you have any trailer interchange agreements with other moving companies?* Yes No N/A Do you have any 409 agreements (military contracts)?* Yes No N/A Please provide names of contracts.* Add RemoveDo you have a formal written safety program?* Yes No N/A Any material changes in your operations in the past 5 years?* Yes No N/A Please provide details.*Any expected or potential changes in the upcoming policy year?* Yes No N/A Please provide details.*Percentage of Operations% Residential*Please enter a number from 0 to 100.% Commercial*Please enter a number from 0 to 100.Types of GoodsPlease specify percentage of types of goods handled, between 0 - 100.Used Household Goods %*Please enter a number from 0 to 100.New Household Goods %*Please enter a number from 0 to 100.Military Household Goods %*Please enter a number from 0 to 100.Office Furnishings %*Please enter a number from 0 to 100.Electronics %*Please enter a number from 0 to 100.Information & Records %*Please enter a number from 0 to 100.Special Products %*Please enter a number from 0 to 100.Total % AutoDo you own any vehicles not scheduled on this policy?* Yes No N/A Please explain. Does anyone other than your company own any scheduled vehicles?* Yes No N/A Please explain.* Do you use contract drivers or Owner/Operators?* Yes No N/A Are contract drivers or Owner/Operators included on your Driver List?* Yes No N/A Do contract drivers or Owner/Operators haul exclusively for you?* Yes No N/A Do you rent/lease vehicles not scheduled on the auto policy?* Yes No N/A What is the average annual expense for this?* Is there a written vehicle maintenance program?* Yes No N/A Does it include regular preventive maintenance?* Yes No N/A Does it include certified mechanics?* Yes No N/A Does it include safety & pre-trip inspections?* Yes No N/A Hiring PracticesIs there a formal applicant screening process?* Yes No N/A Do you receive an application on all new employees?* Yes No N/A Do you obtain and review MVRs prior to hiring?* Yes No N/A Do you review MVRs annually?* Yes No N/A Do you complete a criminal background check prior to hiring?* Yes No N/A Are there written job descriptions with minimum qualifications?* Yes No N/A Are experience, qualifications and references verified for each new hire?* Yes No N/A Do you require a pre-employment physical for all employee drivers?* Yes No N/A Do you require pre-employment drug testing of all drivers, packers and handlers?* Yes No N/A Do you conduct random drug testing of all drivers, packers and handlers?* Yes No N/A Do you lease employees from an employee leasing firm?* Yes No N/A Please provide a copy of your current Auto Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coverages .Max. file size: 100 MB. General LiabilityDoes your company perform on-site office installation/assembly?* Yes No N/A Please provide description of these operations and payroll.*Does your company perform on-site appliance installation/assembly, connect washers or icemakers?* Yes No N/A Please provide description of these operations and payroll.*Do you utilize sub-contractors for either of the above 2 questions?* Yes No N/A Do you provide self-storage services?* Yes No N/A Estimated Annual Sales* Do you have any rigging equipment?* Yes No N/A Do you rent rigging equipment or cranes?* Yes No N/A Do you allow customers access to the warehouse?* Yes No N/A Are there any premises that are leased to others?* Yes No N/A Please provide names, description of their operations, square footage occupied.*Do you secure and maintain GL certificates from all tenants/lessors showing limits equal to or greater than your policy limits and listing your company as Additional Insured?* Yes No N/A Is there a written agreement for all locations that are leased or rented?* Yes No N/A Please provide a copy of your current General Liability Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coverages .Max. file size: 100 MB. Property PropertyAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Building Limit*Contents Limit*BI / EE or Loss of Rents Limit*Are you owner or tenant?* Owner Tenant Owned or leased in what entity name?* Total building Sq. Ft.*Sq. Ft. occupied by you (warehouse)*Sq. Ft. occupied by you (office)*Do you lease space to others? Yes No If yes, provide names and Sq. Ft. for eachNameSq. Ft. Add RemoveOutdoor scales and/or signs?* Yes No If yes, provide value.Year Built* Construction Type* Updates to roof, wiring, plumbing, or heating? Please provide details and dates.UpgradeDetailsDate Add RemoveBuilding Sprinklered?* Yes No Fire Alarm?* Yes No Central Station?* Yes No Installed / Monitored By? Burglar Alarm?* Yes No Central Station?* Yes No Installed / Monitored By? Add PropertyRemove PropertyPlease provide a copy of your current Property Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coverages.Max. file size: 100 MB. Warehouse / CargoDoes your company issue a bill of lading and a warehouse receipt on all moves?* Yes No N/A Are you subject to state regulation or to a Tariff?* Yes No N/A Do you provide labor for on-premises moves?* Yes No N/A Do you ever have off-site or temporary storage?* Yes No N/A Are there any climate controlled storage facilities?* Yes No N/A Do you own self-storage or mini-storage facilities?* Yes No N/A Do you store any goods of others in a self-storage or mini-storage facility not owned by you?* Yes No N/A Do you have containerized self-storage or PODS?* Yes No N/A Do you do any specialized crating?* Yes No N/A Do you hold storage auctions?* Yes No N/A Do you store boats or vehicles?* Yes No N/A Any Exhibition/Trade Shows?* Yes No N/A Requested Cargo Liability LimitBill of Lading*Per Truck*Per Disaster*Moving Equipment Limit*ACV or RCV?* ACV (Actual Cash Value) RCV (Replacement Cost) Is any mobile equipment valued greater than $25,000?* Yes No Warehouse / Cargo (continued)Valuation of PropertyCoverage% Transported (Cargo)*At Limited Liability ($0.60 / lb.)Please enter a number from 0 to 100.% Stored (Warehouse)*At Limited Liability ($0.60 / lb.)Please enter a number from 0 to 100.% Transported (Cargo)*At $3.00/lb. or lowerPlease enter a number from 0 to 100.% Stored (Warehouse)*At $3.00/lb. or lowerPlease enter a number from 0 to 100.% Transported (Cargo)*At more than $3.00/lb. or declared valuePlease enter a number from 0 to 100.% Stored (Warehouse)*At more than $3.00/lb. or declared valuePlease enter a number from 0 to 100.% Transported TotalShould equal 100%% Stored TotalShould equal 100%Valuation% Transported (Cargo)*On an Actual Cash Value (ACV) BasisPlease enter a number from 0 to 100.% Stored (Warehouse)*On an Actual Cash Value (ACV) BasisPlease enter a number from 0 to 100.% Transported (Cargo)*On a Replacement Cost (RCV) BasisPlease enter a number from 0 to 100.% Stored (Warehouse)*On a Replacement Cost (RCV) BasisPlease enter a number from 0 to 100.Other If you have another valuation basis, please specify here.% Transported (Cargo)Please enter a number from 0 to 100.% Stored (Warehouse)Please enter a number from 0 to 100.% Transported TotalShould equal 100%% Stored TotalShould equal 100%Transportation% Transported by Owned Vehicles*Please enter a number from 0 to 100.% Transported by Contractor Vehicles*Please enter a number from 0 to 100.Other % Transported by Other MethodPlease enter a number from 0 to 100.% TotalShould equal 100% Warehouse / Cargo (continued)No Storage?* No Storage (skip this section) Have Storage StorageAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code WLL Limit RequestedArea of Warehouse Non-Temp Military Limit (lbs. x $6.00)% UnusedPlease enter a number from 0 to 100.% RacksPlease enter a number from 0 to 100.% LoosePlease enter a number from 0 to 100.% VaultsPlease enter a number from 0 to 100.Vault Height 2-high 3-high Other Add StorageRemove StoragePlease provide a copy of your current Inland Marine Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coverages.Max. file size: 100 MB. CrimeNo Crime?* No Crime (skip this section) Crime Policy Are regular audits performed?* Yes No N/A Audit frequency* Annual Semi-Annual Quarterly Audits performed by* Staff Public Accountant CPA Audit format* Audit Review Compilation Tax Return Only Is audit made in accordance with generally accepted auditing standards and so certified?* Yes No N/A Does audit include inventory?* Yes No N/A Are all incoming checks stamped “For Deposit Only” as soon as they are received?* Yes No N/A Are all company accounts reconciled against a job/customer each month?* Yes No N/A Are drivers required to present receipts for fuel or other services daily with their bill of lading?* Yes No N/A Is the purchase of company supplies, packing materials, equipment, etc. handled through a purchase order process that requires not only an employee signature but also a general manager or controller signature?* Yes No N/A Is countersignature of checks required?* Yes No N/A Who signs controls?* Will securities be subject to joint control of two or more responsible employees?* Yes No N/A Do you verify transfer instructions purportedly issued by you, an employee, or other management and staff, your vendors and customers?* All instructions are verified. Instructions are verified for all transfer instructions greater than a certain amount. No requirement of transfer instructions is required What amount?*Do you accept credit card payments for moving or storage?* Yes No N/A Do you keep credit card numbers on file?* Yes No N/A Is there a written policy regarding EFTs?* Yes No N/A Should contractors or Owner/Operators be included for crime coverage?* Yes No N/A How many?*Please provide a copy of your current Crime Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coveragesMax. file size: 100 MB. Worker's CompensationNo Worker's Compensation?* No Worker's Compensation (skip this section) Worker's Compensation Policy Do you have a team safety incentive program?* Yes No N/A Do you have currently have a Drug Free Credit?* Yes No N/A Do Owner/Operators have their own worker’s compensation coverage?* Yes No N/A WIth whom?* Do you have current certificates of insurance showing Owner/Operators own worker’s compensation coverage?* Yes No N/A Is group medical coverage offered to eligible employees?* Yes No N/A Percentage of employee participation*Please enter a number less than or equal to 100.Percentage paid for by the employer*Please enter a number less than or equal to 100.Paid sick leave?* Yes No N/A Paid vacation?* Yes No N/A Is there any retirement programs or life insurance offered for drivers?* Yes No N/A Do you have a modified/light duty Return to Work Program?* Yes No N/A Is casual labor used?* Yes No N/A Max number of employees in a vehicle at once?*Please check each of the following safety devices/procedures utilized: Lift Belts Steel-Toe Boots Dollies Lift Gates Formal Lift Training Team Lifting Team Lifting mandatory at? (in lbs.)*Officers*Officer NameTitleIncluded / ExcludedClass CodePayroll Add RemovePlease provide a copy of your current Worker’s Compensation Policy so we can review your current limits and exposures to ensure you are quoted the same or similar coverages.Max. file size: 100 MB. Comments / ExplanationsPlease provide any comments or additional details for any questions here:
