Non Trucking Liability and Occupational Accident Application(s) "*" indicates required fields Step 1 of 7 14% First NameLast NameBusiness Legal NameLegal entity name that is on your articles of incorporation or on file with the Gov. Do you have a DBA?* Yes No What is your DBA?This is your Doing Business As Name. Business Type Individual/Sole proprietorship Partnership Corporation LLC Other Select which type of business you are setup as.What is your FEIN (Federal Tax ID Number)DOT Number of the company you are leased onto?Carrier business name you are leased onto?Provide the Business name of the carrier you are leased onto here.Please upload your Signed Owner Operator agreement between you and Clean Harbors hereMax. file size: 98 MB.Please Be Aware That In The Event Of a Claim, Coverage Can Be Denied If There Is No Active Signed Lease Agreement Between a Motor Carrier and The Insured Under a Non-Trucking Liability Policy Email Cell PhoneMay we text message you?* Yes No Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your garaging address the same as your mailing address? Yes No Premises and Garaging Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Description of operationsSelect operation type(s) Dry Van Refrigerated Flatbed Liquid Tank Dry Bulk Containerized Dump Livestock Hauler Auto Hauler Towing Operation Hot Shot Box Truck Description of the commodties being hauledDescribe each type of Cargo Hauled% of HaulingAverage Value of LoadMax Value of Load Add RemoveDo you operate in more than one state? Yes No If yes, please list states entered.Show largest cities entered?This will help us build a zone rating and provide the most competitive pricing! Please check if these apply to your company... Do you? Pull double trailers? Pull triple trailers? Rent or lease your vehicles to others? Hire any vehicles? Attach a copy of rental or lease agreement used if applicable.Max. file size: 98 MB. Driver informationDriver InformationFirst and Last NameDate of BirthDriver's license state and DL numberYears of CDL experienceHire date Add RemoveUpload a driver list here.Max. file size: 98 MB.Please include the following with the list. Years of CDL experience Date of hire No, of accidents and moving violations in the last five years.Vehicle sectionVehicle ScheduleVehicle YearMakeModelVINValue Add RemovePlease include the following for each tractor and trailer. Year, make, model and type (truck, tractor, trailer, etc.) VIN number, Gross vehicle weight (GVW) Annual mileage per vehicle and also the radius of operation. Please describe your vehicle maintenance programGo into detail about proactive maintenance of your vehicles and equipment. Please upload list of vehicles here if easier.Max. file size: 98 MB.Please include date purchased, cost when purchased, any permanently attached equipment to be covered, and total stated amount to be insured for for each unit. Loss sectionHave you had any claims in the last 5 (five) years? Yes No If yes, please explain the lossMake sure to include the date, amount paid and description of the loss. Attached hard copy Loss runs from your prior carrier here Drop files here or Select files Max. file size: 98 MB. Please include loss runs for each carrier over the last 3 years. Insurance coverage limits requestedNon Trucking Auto Liability Combined Single Limit BI & PDUnderinsured/Uninsured Motorist Liability CoverageMedical PaymentsPersonal Injury Protection(Where Applicable)Common limits include $1,000,000 or more for auto liability. $100,000 or more for Underinsured/Uninsured Motorist Liability Coverage. $10,000 or more in Medical Payment coverage. $10,000 or $35,000 or more for Personal Injury Protection. *Please note that these coverage limits may differ or not be what you are required or need to carry. Please refer to any and all contracts and requirements to figure out what actual limits you need to carry. This is not a recommendation of coverage or limits of coverage from All Lines Associates, Inc. DBA: All Lines Insurance DBA: Valley Trucking Insurance or its affiliates and or representatives. Insurance coverage limits requestedCargo Coverage LimitComprehensive and collision deductibles desired for equipmentNon Owned Trailer Physical Damage limit and deductible(s) requested Add RemoveInsurance continued... Would you like to add the following?Towing Coverage Y/NDowntime Coverage Y/NRental Reimbursement Y/NTrailer Interchange? Indicate Amount Add RemoveAre you currently insured?* Yes No Who is your current insurance company?*If a new venture prior personal auto insurance will count as well. How much do you pay annually?*What is the total insurance cost currently you are paying with your current company?Attached a copy of your current insurance and any renewals you have from your current insurance company. Drop files here or Select files Max. file size: 98 MB. Are you the only financial responsibility? Yes No Financial Responsibility SSN*Owner's Name or Financial responsibility First Last Owner's Date of BirthSSN for the financial responsibile person for the companyMisc Notes or details you want to share Occupational Accident / Workers CompDo you need Occupational Accident or Workers' Compensation coverage?* Yes No Which coverage type do you need?* Occupational Accident Workers' Compensation Who Needs Coverage?*W-2, 1099, or Owner?Driver NameProjected Annual Salary Add RemovePlease List All Owners and/or Contractors That Need To Be Listed Under This PolicyWho Are The Beneficiaries For DriversBeneficiary #1 Full Name, Date of Birth (MM/DD/YY), SSN, Email Address, Phone, % of BenefitBeneficiary #2 Full Name, Date of Birth (MM/DD/YY), SSN, Email Address, Phone, % of Benefit Add RemovePlease List 2 Beneficiaries Per Driver Listed Above In The Same Order As The Drivers Added Above. (Who Will Receive Benefits In The Event Of a Fatal Accident)Consent* I agree to the following:No coverage is bound until the company advises the applicant or its representative that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges that the Applicant's representative named below is acting as applicant's agent and not on behalf of the company. The applicant's representative has no authority to bind coverage, may not accept any funds for the company, and may not modify or interpret the terms of the policy. The applicant agrees that the foregoing statements and answers are true and correct. The applicant request the company to rely on its statements and answers in issuing any policy or subsequent renewal. The applicant agrees that if its statements and answers are materially false, the company may rescind any policy or subsequent renewal it may issue. If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be attached to the policy which increases the Company's liability, the Applicant agrees to reimburse the company in accordance with the terms of that endorsement. The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any other matter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect. The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation. The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).
