TAS Insurance Group, Inc.

Submission Checklist

Target Date of Coverage: ___________ Today’s Date: ___________

Agent Name:__________________ Contact Name:_____________________________

Email Address: _____________________________________

 

Phone Number: _____________________Fax Number: _________________________

 

ACCOUNT INFORMATION:

Account Name:____________________ Contact Name: _________________________

Address: ________________________________________

 

City, State, Zip:___________________________________

 

Phone Number: _____________________Fax Number: _________________________

1. Does Motor Carrier have a full-time Safety Director? 0 YES 0 NO

2. If yes, name: Phone:___________________ Fax:_______________________

3. Copy of driver qualification criteria including minimum driver acceptability requirements.

4. Does Motor Carrier have a safety policy?  0 YES 0 NO

(need copy if written policy exists)?

5. Copy of Owner-Operator lease agreement.

6. Copy of Lease Purchase agreement.

7. Commodities hauled (give description and percentage if haz mat):
________________________________________________

8. Do drivers load and/or unload? 0 YES 0 NO

9. Radius of Operations. 1-50_______50-200_____200+____

10. Motor Carrier Number: ________________________

11. FEIN Number: _______________________________

Physical Damage and Non-Trucking Liability

1. Equipment list (owner’s name, address, equipment, year, make, VIN#, value, loss payee).

2. Driver list (name, address, DOB, and CDL#, including state of issue).

3. Loss runs (minimum 3 year history).

Occupational Accident

1. Driver list (owner’s name, owner’s address, driver’s name, driver’s address, date of birth, CDL #, state of license).

2. Loss runs (minimum 3 year history).