APPLICANT INFORMATION

First Named Insured: ___________________________________________________________________________________________

Mailing Address: _______________________________________________________________________________________________

Other Named Insureds: _________________________________________________________________________________________

Partnership/Corporation/Individual: ______________________________________________________________________________

Years in Business: ______________________________________________________________________________________________

Description of Operations: ______________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Website Address: ______________________________________________________________________________________________

Inspection Contact (Name): _____________________________________________________________________________________

Telephone: ____________________________________________________________________________________________________

Email: _________________________________________________________________________________________________________

Additional Interests (include names and interest such as loss payee, mortgagee, etc.):

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

GENERAL POLICY INFORMATION

Effective Date/Expiration Date: __________________________________________________________________________________

Billing (Agency or Direct): _______________________________________________________________________________________

Payment Plan: _________________________________________________________________________________________________

UNDERWRITING INFORMATION

Principal Commodities Carried Including Percentage of Total

COMMODITY PERCENT MAXIMUM VALUE AVERAGE VALUE

A P P L I C A T I O N

Motor Truck Cargo Application (Commercial Inland Marine)

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If any of the Following Commodities are handled, check and State Maximum Value in Any One Load:

Alcoholic Beverages $_______________ Produce $_______________

Auto Tires or Tubes $_______________ Frozen Meats $_______________

Electronics $_______________ Textiles $_______________

Explosives $_______________ Tobacco Products $_______________

LIMITS OF LIABILITY

Per Vehicle: $_______________ Per Occurrence: $_______________ Deductible: $_______________

Refrigeration Breakdown Coverage needed? Yes No

If Yes, Reefer Limit: $_______________ Deductible: $_______________

PERIOD POWER UNITS OWNED POWER UNITS LEASED REVENUE MILES

Current Year

1st Prior

2nd Prior

3rd Prior

4th Prior

TERMINAL COVERAGE Yes No

If Yes, complete below:

LOCATION LOCATION ADDRESS LIMIT

1 $

2 $

3 $

4 $

5 $

LOCATION CONSTRUCTION TYPE SQUARE

FOOTAGE

PUBLIC PROTECTION

CLASS

SPRINKLERED SECURITY INFO

1 Yes No

2 Yes No

3 Yes No

4 Yes No

5 Yes No

RADIUS OF OPERATIONS (One way trip distances by percentage — Totals 100%)

0-100 Miles ______% 100-250 Miles ______% 250-500 Miles ______% Over 500 Miles ______%

Driver Safety and Maintenance

1. Is there a full time safety director? Yes No

2. Safety Director name: _____________________________________________________________________________________

3. Are there scheduled formal safety meetings? Yes No

How often?_______________________________________________________________________________________________

4. Is driver attendance mandatory? Yes No

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The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653

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5. Is there a driver award or bonus plan? Yes No

6. Is there an accident review board? Yes No

7. Is there a formal safety manual of driver handbook? (Please attach with Application.) Yes No

8. Are driver files reviewed? Yes No

9. How often are MVRs reviewed? ____________________________________________________________________________

10. What is the minimum age of drivers hired? __________________________________________________________________

11. What are the minimum years of experience for new drivers? ___________________________________________________

12. Number of drivers under 24 ______ and over 65 ______

13. Are owner operators having the same requirements as company drivers? Yes No

14. Is there a vehicle maintenance program? Yes No

Please describe: __________________________________________________________________________________________

15. Are records maintained? Yes No

16. Submit along with this Application:

a. Vehicle Schedule b. MVRs and Driver’s List c. Prior Carrier Loss Runs 5 Years

PRIOR CARRIER INFORMATION

YEAR CARRIER POLICY NUMBER PREMIUM LOSSES At tach a min imum of 3 years of hard copy loss h i s tor y

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICANT AGENT

Name: _______________________________________________ Name: ________________________________________________

Position: _____________________________________________ Position: ______________________________________________

Address (City, State, Zip): Address (City, State, Zip):

_____________________________________________________ ______________________________________________________

_____________________________________________________ ______________________________________________________

_____________________________________________________ ______________________________________________________

Signature: ____________________________________________ Signature: ____________________________________________

Date: ________________________________________________ Date: _________________________________________________