RSG Specialty, LLC - Commercial Auto Application

Agency Contact Information
*Agent's Name
Agent's Phone	() -
Agent's Fax	() -
*Agent's Email

In order to help us serve you better, please provide an overview of this application:

*Proposed Effective Date

*Garaging State:

*Garaging County:

*Comm Auto Business Class:

Trucking

Business Auto

*Comm Auto Business Type:
(check all that apply)

(please select a Comm Auto Business Class)

*Years In Business:

(under current name)

*Power Unit Count:

*Max Radius of Operation:

Miles

*Commodities:
(check all that apply)

*Coverages:
(check all that apply)

Applicant Information

*Legal Entity

DBA (if applicable)

*Mailing Address 1

Mailing Address 2

*City, *State, *Zip, *County

*Phone

() -

*Email

* Entity type

Garage Address (Click here to use mailing address)

*Garage Address 1

Garage Address 2

*City, *State, *Zip, *County

* Experience
Year business started: (under this name) Total prior years’ operating under primary auto liability insurance in your name:

Owner

Other

Radius of Operations
0 - 50mi	51 - 75mi	76 - 100mi	101 - 150mi	151 - 200mi	201 - 300mi	301 - 500mi	501 - 1000mi	1001 +
%	%	%	%	%	%	%	%	%

Five Most Common Hauls By Destination:

1.

2.

3.

4.

5.

*Commodity Summary: Add

Cargo Hauled

%

Maximum Value

Average Value

*Schedule of Drivers: Add

Name (Last,First,MI)

Date of Birth
MM/DD/YYYY

State & License #

Three Year Accident & Violation History
Minor Violations Past 12/36 Months	Major Violations Past 12/36 Months	NAF Accidents Past 12/36 Months	AF Accidents Past 12/36 Months

Experience
Driving
Similar
Vehicle
(Years)

Date of Hire
MM/DD/YYYY

*Vehicle Schedule: Add

Year

Trade Name

Type of Vehicle

Description of Vehicle

Gross Vehicle Weight

Current Value

Maximum Radius

Owned/Leased

Prior Three Year Carrier Information: *If new venture fill out "Prior Employer Info (New Ventures Only)" below.

	Liability Carrier	Physical Damage Carrier	Power Unit Count	Receipts Generated	# Losses Liability	# Losses Physical Damage	Amount Paid
Current Year							$
One Year Prior							$
Two Years Prior							$

Prior Employer Info (New Ventures Only)

Employer	Dates of Employment From - To	Type of Unit	DOT #	Motor Carrier #
	-
	-

*Limits & Deductibles

Primary

Non-Trucking

Bodily Injury Liability / Property Damage Liability

CSL

Medical Payments

Personal Injury

Each Person

Medical Expenses

Work Loss

Funeral Expenses

Accidental Death

Combination

Extraordinary Medical Benefits

Uninsured Motorist Liability

CSL

Underinsured Motorist Liability

CSL

Physical Damage

Specified Cause Of Loss

Comprehensive

$ Deductible

Collision

$ Deductible

Cargo

$ Limit $ Deductible

General Liability

$ General Aggregate
$ Per Occurrence

*Major Metro Exposures
%	Zone	Description	%	Zone	Description	%	Zone	Description	%	Zone	Description
	01	Atlanta		12	Hartford		23	Minn / St. P		34	St. Louis
	02	Balt / Wash		13	Houston		24	Nashville		35	Salt Lake City
	03	Boston		14	Indianapolis		25	New Orleans		36	San Francisco
	04	Buffalo		15	Jacksonville		26	NY City		37	Tulsa
	05	Charlotte		16	Kansas City		27	Oklahoma City		38	Gulf
	06	Chicago		17	Little Rock		28	Omaha		39	Southeast
	07	Cincinnati		18	Los Angeles		29	Phoenix		40	Eastern
	08	Cleveland		19	Louisville		30	Philadelphia		41	New England
	09	Dallas/Ft. W		20	Memphis		31	Pittsburgh		42	Remainder of Country
	10	Denver		21	Miami		32	Portland
	11	Detroit		22	Milwaukee		33	Richmond

Comments

Your application has successfully been submitted.

A copy of your submitted application has been emailed to you.

Coverage	Premium	Limit	Deductible	Taxes/Fees


Total

Forms and Endorsements

,

You may now close this window.

There has been a problem submitting your application. Please select one of the following options to continue.

I'd like to look over my application again for accuracy and resubmit. (recommended)

I'd like to submit the data that I've already entered - as is - directly to an underwriter.

You may now close this window.

Based on the info entered, it appears we’re currently unable to offer a market for this account. Please do not hesitate to email us at RTJohnstown@rtspecialty.com if we can help you further.

You may now close this window.

We're sorry, but there was a problem with our preliminary check of your application. Our IT has been made aware of the problem, and will notify you when it is corrected.

You may now close this window.

Cargo - Prior 3 Year Carrier Information
	Carrier	# Losses	Amount Paid
Current Year			$
1 Yr Prior			$
2 Yr Prior			$

Commodity Specifics: