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Secure Transport Application
Transport Application
rootscannabis
2019-03-19T18:43:05-04:00
A- Secure Transport Application
Do you deliver or transport cannabis living plants or harvested goods?
Yes
No
Do you deliver to businesses?
Yes
No
Do you deliver to consumers?
Yes
No
Are any vehicles used to haul steel?
Yes
No
Do any vehicles require a hazardous materials placecard?
Yes
No
President/CEO Information
First Name:
Last Name:
Home Address:
Involved in the daily operation of the business?
Yes
No
Is this person required to be a driver?
Yes
No
Drivers License Number:
Vehicles
How many vehicles does the business own?
0
1
2
3
4
5
Are annual motor vehicle reports of all drivers ordered?
Yes
No
Do you allow firearms or weapons in the vehicle?
Yes
No
Vehicle 1
VIN:
Category:
Bus
Car
Cargo Van
Hearse
Limo
Mini Van
Motor Home
Passenger Van
Pickup Truck
SUV
Truck
Emergency Vehicle
Military Vehicle
Year:
Make:
Model:
Garaging Zip Code:
Radius One Way:
100 miles intrastate (within MI only)
100 miles interstate (goes outside MI)
200 miles intrastate (within MI only)
200 miles interstate (goes outside MI)
300 miles intrastate (within MI only)
300 miles interstate (goes outside MI)
500 miles intrastate (within MI only)
500 miles interstate (goes outside MI)
Unlimited Miles
Is vehicle used for:
Business
Personal
Both
Is the vehicle used to haul goods on a For-Hire basis?
Yes
No
Does this vehicle need comprehensive or collision coverage?
Yes
No
Comprehensive Deductible:
$100
$250
$500
$1,000
$2,500
$5,000
Collision Deductible:
$100
$250
$500
$1,000
$2,500
$5,000
Collision Type:
Limited
Standard
Broad
What is the total value of all permanently attached equipment (including aftermarket parts, mounted equipment, GPS systems, security systems and modificiations)?
$0-$2,000
More than $2,000
Permanently Attached Equipment Value :
$
(Enter the total replacement cost for all permanently attached equipment. Permanently attached equipment means equipment and devices that are permanently installed or attached to your insured auto. Permanently attached equipment also includes)
Current Vehicle Value:
$
(The current retail value of the vehicle excluding any permanently attached equipment. The easiest way to establish a current vehicle value is to consult a blue book publication. Other possibilities include consulting with a dealer/manufacturer or checking internet sites)
Will there be a lienholder on the vehicle?
Yes
No
Name:
Additional Vehicle
Add
Remove
Drivers
Number of Drivers:
0
1
2
3
4
5
6
7
8
9
10
First Name
Middle Initial
Last Name
Date of Birth
Marital Status
Single
Married
Is this driver excluded?
Yes
No
License State
License Number
Commercial Driver’s License (CDL) :
Yes
No
(Drivers who have successfully completed knowledge and skill tests regarding the safe operation of commercial vehicles are issued a Commercial Driver’s License or CDL)
Is an SR 22 Required?
Yes
No
List all accidents
(Both at fault and not at fault and violations for the last 35 months, with description of accident or violation and approximate date)
Add
Remove
Underwriting
Does the business currently have an auto insurance policy?
Yes
No
Carrier:
Current Policy Number:
Current Policy Effective Date:
Current Policy Expiration Date:
Current Liability Limits:
$
Has insured had continuous coverage for at least one year?
Yes
No
Year current business was established:
Coverage Requested
BI-PD Liability Limits:
300 CSL
500 CSL
750 CSL
1M CSL
1.5M CSL
2M CSL
PIP Coverage:
Full Medical
Covered under Work Comp (All drivers are covered under a worker’s comp policy (only eligible if ALL vehicles have NO PERSONAL USE)
Rental Reimbursement:
$30 per day
$40 per day
$50 per day
Roadside Assistance:
Yes
No
Signature
I warrant the above to be true and understand the insurance contract will be considered based on my warranty.
Electronic Signature
*
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