← 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 AffiliationAdditional 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.OtherIf 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 WarehouseNon-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:
