CARGO PROGRAM
			RATER
	* Insured Name:
	* Address:
	* City:
	* State:			Select Delaware District of Columbia Maryland New Jersey Pennsylvania Virginia
	* Zip Code:
	* Number of years in this business:
	* Current Carrier:
	* In the past 3 years, has the applicant			Select Yes No
	had authority under a different name:
		(If answer is "YES" please provide details)
	* Has the applicant had any losses in the past 3 years:			Select Yes No
		(If answer is "Yes" please provide details)
	* Are all drivers between the ages of 23 and 65:			Select Yes No
		(If answer is "NO" please provide details)
	* Do all drivers have at least 2 years experience			Select Yes No
	transporting this commodity:
		(If answer is "NO" please provide details)
	* Has any driver had any major violations
	in the past 3 years:			Select Yes No
		(If answer is "YES" please provide details)
	* Has any driver had any minor violations			Select Yes No
	in the past 3 years:
		(Please provide details)
	* Total number of power units:
	(Please call if more than 5 units for better pricing)
	* Per Vehicle Limit of Insurance requested:
	(Please call if over $75,000 for better pricing)
	* Radius of Operation:			Select Under 50 Miles 50 to 300 Miles Over 300 Miles
	* Current Premium:
	* Requested Effective Date:
	* Please describe the insureds operation:
	* Has coverage been cancelled or non-renewed			Select Yes No
	in the past 3 years:
		(If answer is "YES" please provide details)
	* Has applicant filed for bankruptcy in the past 3 years:			Select Yes No
		(If answer is "YES" please provide details)
	* Does the applicant ever leave loaded trailers			Select Yes No
	detached from the power units:
		(If answer is "YES" please provide details)
	* Does applicant ever leave trailers unattended:			Select Yes No
		(If answer is "YES" please provide details)
	* Does the insured utilize "Double Trailers":			Select Yes No
	* Please describe commodities hauled:
	* Please advise class of commodity hauled from below chart:			Select Class 1 Class 2 Class 3 Class 4 Class 5
	Class 1	Class 2	Class 3
	Bricks	Appliances	Beer - No Liquor
	Canned Goods	Auto Parts - NOC	Boat
	Cement	Books	Car
	Cotton	Building Materials	Electronic Parts
	Feed	Cheese / Dairy	Fresh Frozen Meat
	Grain	Clothing	Frozen Foods
	Fgravel	Concrete	Motorcycle
	Hay & Straw	Farm Equipment	Oilfield Equipment
	Logs	Fertilizer - Bulk	Petroleum Products
	Lumber	Groceries	Poultry
	Non-Perishable	Hardware	Seafood
	Food	Heavy Machinery	Sporting Goods
	Paper Goods	Machinery - NOC	Textiles
	Produce	Magazines	Tires
	Recycled Materials	Periodicals	Tobacco - Raw
	Sand	Milk
	Seed	Paint	Class 4
	Steel	Plastic Goods	Computer Equip
	Wood - NOC	Rubber Goods	Cosmetics
		Soap Products	Electronics
	* Would you like to increase your deductible to $2,500 (from $1,000):			Select Yes No
	* Would you like to include "Refrigeration Breakdown" coverage:			Select Yes No
	* Would you like to include "Trailer Interchange" coverage:			Select Yes No
	* If "Trailer Interchange is to be included, please provide
	the maximum trailer value:
	* Are Interstate Commerce Commission Filings (ICC) required:			Select Yes No
	* Year of Vehicle	Make of Vehicle	Model of Vehicle	Vehicle Identification Number
	Agency Name:
	Agency Address:
	Agency City, State & Zip:
	Agency Phone:
	Agency Fax:
	Agency E-Mail:
	Contact Person:
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