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{"sheet":"APPLICATION","index":0,"n_rows":304,"n_cols":28,"rows_kept":304,"cut":false,"hidden":false,"merged":[[144,27,144,29],[145,27,145,29],[146,27,146,29],[147,27,147,29],[148,27,148,29],[149,27,149,29],[150,27,150,29],[144,17,144,26],[145,17,145,26],[146,17,146,26],[147,17,147,26],[148,17,148,26],[149,17,149,26],[150,17,150,26],[147,2,147,13],[149,2,149,13],[150,2,150,13],[148,2,148,13],[144,14,144,16],[145,14,145,16],[146,14,146,16],[147,14,147,16],[148,14,148,16],[149,14,149,16],[150,14,150,16],[144,2,144,13],[145,2,145,13],[146,2,146,13],[50,3,50,29],[52,27,52,29],[52,16,52,17],[47,24,47,29],[83,3,83,29],[63,3,63,29],[71,26,71,29],[73,27,73,29],[75,17,75,29],[78,3,78,29],[13,5,13,15],[14,6,14,11],[14,16,14,19],[14,23,14,29],[15,6,15,29],[22,17,22,29],[23,17,23,29],[26,3,26,29],[9,2,9,29],[10,20,10,29],[10,6,10,15],[16,3,16,11],[16,14,16,22],[16,24,16,29],[11,3,11,11],[11,14,11,22],[11,24,11,29],[12,6,12,11],[12,16,12,29],[13,23,13,25],[13,27,13,29],[13,19,13,21],[17,9,17,29],[95,27,95,29],[102,3,102,29],[107,2,107,9],[108,2,108,9],[109,2,109,9],[107,23,107,29],[108,23,108,29],[109,23,109,29],[18,3,18,11],[18,14,18,22],[18,24,18,29],[90,3,90,29],[93,3,93,29],[31,3,31,29],[34,3,34,29],[36,28,36,29],[37,15,37,19],[37,10,37,11],[53,27,53,29],[59,20,59,29],[60,25,60,29],[60,19,60,20],[40,3,40,29],[43,3,43,29],[114,16,114,22],[115,16,115,22],[115,2,115,9],[107,10,107,15],[108,10,108,15],[109,10,109,15],[110,10,110,15],[111,10,111,15],[112,10,112,15],[113,10,113,15],[114,10,114,15],[115,10,115,15],[110,2,110,9],[111,2,111,9],[112,2,112,9],[113,2,113,9],[114,2,114,9],[115,23,115,29],[118,10,118,15],[118,16,118,22],[118,23,118,29],[106,2,106,9],[106,10,106,15],[106,16,106,22],[106,23,106,29],[117,2,117,9],[117,10,117,15],[117,16,117,22],[118,2,118,9],[110,23,110,29],[111,23,111,29],[112,23,112,29],[113,23,113,29],[114,23,114,29],[107,16,107,22],[108,16,108,22],[109,16,109,22],[110,16,110,22],[111,16,111,22],[112,16,112,22],[113,16,113,22],[120,24,120,26],[120,27,120,29],[121,2,121,7],[122,2,122,7],[123,2,123,7],[121,10,121,11],[122,10,122,11],[123,10,123,11],[121,14,121,23],[122,14,122,23],[123,14,123,23],[121,27,121,29],[122,27,122,29],[123,27,123,29],[120,2,120,7],[120,8,120,9],[120,10,120,11],[120,12,120,13],[120,14,120,23],[127,12,127,13],[124,2,124,7],[125,2,125,7],[126,2,126,7],[127,2,127,7],[121,8,121,9],[122,8,122,9],[123,8,123,9],[124,8,124,9],[125,8,125,9],[126,8,126,9],[127,8,127,9],[129,9,129,15],[129,16,129,22],[129,23,129,29],[124,14,124,23],[125,14,125,23],[126,14,126,23],[127,14,127,23],[121,24,121,26],[122,24,122,26],[123,24,123,26],[124,24,124,26],[125,24,125,26],[126,24,126,26],[127,24,127,26],[124,10,124,11],[125,10,125,11],[126,10,126,11],[127,10,127,11],[121,12,121,13],[122,12,122,13],[123,12,123,13],[124,12,124,13],[125,12,125,13],[126,12,126,13],[130,16,130,22],[131,16,131,22],[132,16,132,22],[133,16,133,22],[134,16,134,22],[124,27,124,29],[125,27,125,29],[126,27,126,29],[127,27,127,29],[130,23,130,29],[130,2,130,8],[131,2,131,8],[132,2,132,8],[133,2,133,8],[134,2,134,8],[131,9,131,15],[132,9,132,15],[133,9,133,15],[134,9,134,15],[130,9,130,15],[136,2,136,8],[136,9,136,15],[136,16,136,23],[136,24,136,26],[136,27,136,29],[131,23,131,29],[132,23,132,29],[133,23,133,29],[134,23,134,29],[138,2,138,8],[138,9,138,15],[138,16,138,23],[138,24,138,26],[138,27,138,29],[137,2,137,8],[137,9,137,15],[137,16,137,23],[137,24,137,26],[137,27,137,29],[140,2,140,8],[140,9,140,15],[140,16,140,23],[140,24,140,26],[140,27,140,29],[139,2,139,8],[139,9,139,15],[139,16,139,23],[139,24,139,26],[139,27,139,29],[142,2,142,8],[142,9,142,15],[142,16,142,23],[142,24,142,26],[142,27,142,29],[141,2,141,8],[141,9,141,15],[141,16,141,23],[141,24,141,26],[141,27,141,29],[162,6,162,7],[162,9,162,10],[163,6,163,7],[163,9,163,10],[164,6,164,7],[164,9,164,10],[159,6,159,7],[159,9,159,10],[160,6,160,7],[160,9,160,10],[161,6,161,7],[161,9,161,10],[160,11,160,14],[161,11,161,14],[152,11,152,14],[153,11,153,14],[154,11,154,14],[155,11,155,14],[156,11,156,14],[152,6,152,10],[153,6,153,7],[153,9,153,10],[154,6,154,7],[154,9,154,10],[156,6,156,7],[156,9,156,10],[157,6,157,7],[157,9,157,10],[158,6,158,7],[158,9,158,10],[155,6,155,7],[155,9,155,10],[160,17,160,20],[161,17,161,20],[162,17,162,20],[163,17,163,20],[164,17,164,20],[162,11,162,14],[163,11,163,14],[164,11,164,14],[152,15,152,16],[153,15,153,16],[154,15,154,16],[155,15,155,16],[156,15,156,16],[157,15,157,16],[158,15,158,16],[159,15,159,16],[160,15,160,16],[161,15,161,16],[162,15,162,16],[163,15,163,16],[164,15,164,16],[157,11,157,14],[158,11,158,14],[159,11,159,14],[155,21,155,23],[152,17,152,20],[153,17,153,20],[154,17,154,20],[155,17,155,20],[156,17,156,20],[157,17,157,20],[158,17,158,20],[159,17,159,20],[161,21,161,23],[162,21,162,23],[163,21,163,23],[164,21,164,23],[152,24,152,26],[153,24,153,26],[154,24,154,26],[155,24,155,26],[156,24,156,26],[157,24,157,26],[158,24,158,26],[159,24,159,26],[160,24,160,26],[161,24,161,26],[162,24,162,26],[163,24,163,26],[156,21,156,23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[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,"Commercial Trucking Application"]
[null,null,"Agency name",null,null,null,null,null,null,null,null,null,null,null,null,null,"Producer's name"]
[null,null,"City",null,null,null,null,null,null,null,null,null,"State",null,null,null,null,null,null,null,null,null,null,"Zip"]
[null,null,"Phone Number",null,null,null,null,null,null,null,null,null,"Email Address"]
[null,null,"Insured Name",null,null,null,null,null,null,null,null,null,null,null,null,null,"Effective Date",null,null,null,null,null,"DOT#",null,null,null,"FEIN #"]
[null,null,"Contact Person",null,null,null,null,null,null,null,null,null,"Phone Number",null,null,null,null,null,null,null,"Email Address"]
[null,null,"Mailing Address"]
[null,null,"City",null,null,null,null,null,null,null,null,null,"State",null,null,null,null,null,null,null,null,null,null,"Zip"]
[null,null,"Garaging Address (if different)"]
[null,null,"City",null,null,null,null,null,null,null,null,null,"State",null,null,null,null,null,null,null,null,null,null,"Zip"]
[]
[null,null,"Underwriting Questions"]
[null,null,"Type of business:"]
[null,null,"How many years has the company operated under its own DOT authority?"]
[null,null,"How many years has the company been under the current management?"]
[null,null,null,null,null,"Any policy coverage declined, cancelled, or non-renewed during the prior three years for any premises or operations?"]
[null,null,null,"(Missouri Applicants - Do not answer this question)  If yes, explain"]
[]
[]
[null,null,null,null,null,"Has applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last five years?"]
[]
[null,null,null,null,null,"Do you transport any hazardous commodities or waste? If yes, explain"]
[]
[]
[null,null,null,null,null,"Do you lease any property, mobile equipment, drivers, and/or vehicles to others? If yes, explain"]
[]
[]
[null,null,null,null,null,"Are you requesting trailer interchange coverage? If yes, average number of trailer interchange days per month"]
[null,null,null,"Average number of units per day ",null,null,null,null,null,null,null,null,"Limit desired"]
[]
[null,null,null,null,null,"Have there been any major changes in your operations during the last five years? If yes, explain "]
[]
[]
[null,null,null,null,null,"Do you lease onto another motor carrier? If yes, list the name of the motor carrier "]
[]
[]
[null,null,null,null,null,null,null,"Does the lease agreement require that you provide primary auto liability insurance?"]
[]
[null,null,null,null,null,"Do you have any brokerage or freight forwarding exposure? If yes, list anticipated revenue"]
[]
[null,null,null,null,null,null,null,"Do you have an active brokerage authority? If yes, list the US DOT# for the brokerage authority"]
[]
[]
[null,null,null,null,null,"Do you utilize any owner/operators? If yes, how many ",null,null,null,null,null,null,null,null,null,null,null,null,"Are they permanently leased or trip leased?"]
[null,null,null,"Does the lease agreement require the owner/operator to provide primary liability insurance? ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Limits required? "]
[]
[null,null,null,null,null,"Are owner/operators subject to the same maintenance requirements as owned equipment?"]
[]
[null,null,null,null,null,"Are owner/operators subject to the same driver requirements as company employees?"]
[]
[null,null,null,null,null,"Do you use any sub-haulers to haul freight? If yes, list annual cost of hire"]
[null,null,null,"Does the lease agreement require the sub-hauler to carry liability insurance? ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Limits required?"]
[]
[null,null,null,null,null,"Are passengers ever allowed to accompany the driver? If yes, explain"]
[]
[]
[null,null,null,null,null,"Do you participate in a drug testing program?"]
[]
[null,null,null,null,null,"Do your driver files conform to DOT requirements?"]
[]
[null,null,null,null,null,"Do you pull and review PSP reports prior to hiring drivers?"]
[]
[null,null,null,null,null,"Do you require all drivers to be 23 years or older? If no, what is your minimum driver age requirement"]
[]
[null,null,null,null,null,"Do you require all drivers to have at least two years of experience? If no, what is your minimum requirement"]
[]
[null,null,null,null,null,"Do you use drivers from training schools? If yes, how many"]
[]
[null,null,null,null,null,"Is all equipment operated under the applicant's authority scheduled on this application? If not, explain"]
[]
[]
[null,null,"General Liability Questions"]
[null,null,null,null,null,"Do your operations consist of any distributing, storing, treating, discharging, applying, disposing, or transporting of "]
[null,null,null,"flammable, explosive, and/ or hazardous waste or radioactive materials? If yes, explain"]
[]
[]
[null,null,null,null,null,"Do you sell any product(s) on a wholesale or retail basis?"]
[]
[null,null,null,null,null,"Do you derive any revenue from warehousing operations?"]
[]
[null,null,null,null,null,"Do you perform service/maintenance work on non-owned equipment? If yes, explain"]
[]
[]
[null,null,null,null,null,"Do you operate a tank wash or trailer wash facility? If yes, explain"]
[]
[]
[null,null,null,null,null,"Do you have any blending or storage operations? If yes, what percentage of revenue does this represent?"]
[]
[null,null,null,null,null,"Do you have tenants?"]
[]
[null,null,null,null,null,"Do you set up or install any products for third parties as part of your operation (furniture, appliances, etc……)?"]
[]
[null,null,null,null,null,"Do you engage in any operations other than trucking for hire? If yes, explain"]
[]
[]
[null,null,"Exposure Information"]
[null,null,"Equipment Information"]
[null,null,"Vehicle Type",null,null,null,null,null,null,null,"Company Owned Units",null,null,null,null,null,"Leased Units (w/o driver)",null,null,null,null,null,null,"Owner/Operator Units"]
[null,null,"Tractor"]
[null,null,"Trailer"]
[null,null,"Extra heavy Trucks (45,000+ lbs.)"]
[null,null,"Heavy Trucks (20,001 - 45,000 lbs.)"]
[null,null,"Medium Trucks (10,001 - 20,000) lbs."]
[null,null,"Light Trucks (0 - 10,000 lbs.)"]
[null,null,"Service Trucks"]
[null,null,"Private Passenger Autos"]
[null,null,"Yard Tractors"]
[null,null,"Radius of Operations by Percentage"]
[null,null,"0 - 50 Miles",null,null,null,null,null,null,null,"51 - 200 Miles",null,null,null,null,null,"201+ Miles"]
[]
[null,null,"Location Information"]
[null,null,"City",null,null,null,null,null,"State",null,"Zip",null,"% of Unit",null,"Description of Operations",null,null,null,null,null,null,null,null,null,"Non-trucking Payroll",null,null,"Warehouse Sq. Ft."]
[]
[]
[]
[]
[]
[]
[]
[null,null,"Upcoming, Current, and Historical Information"]
[null,null,null,null,null,null,null,null,null,"Average Revenue Units",null,null,null,null,null,null,"Revenue",null,null,null,null,null,null,"Mileage"]
[null,null,"Upcoming term (estimate)"]
[null,null,{"$f":"(TEXT(G154,\"m/d/yyyy\")&\" \"&I154&\" \"&TEXT(J154,\"m/d/yyyy\"))","v":" to "}]
[null,null,{"$f":"(TEXT(G155,\"m/d/yyyy\")&\" \"&I155&\" \"&TEXT(J155,\"m/d/yyyy\"))","v":" to "}]
[null,null,{"$f":"(TEXT(G156,\"m/d/yyyy\")&\" \"&I156&\" \"&TEXT(J156,\"m/d/yyyy\"))","v":" to "}]
[null,null,{"$f":"(TEXT(G157,\"m/d/yyyy\")&\" \"&I157&\" \"&TEXT(J157,\"m/d/yyyy\"))","v":" to "}]
[null,null,"Additional Named Insured Information"]
[null,null,"Named Insured",null,null,null,null,null,null,"Description of Operations",null,null,null,null,null,null,"Relationship to Primary Named Insured",null,null,null,null,null,null,null,"DOT #",null,null,"Vehicle Owned (Y/N)"]
[]
[]
[]
[]
[]
[]
[null,null,"Commodities Hauled"]
[null,null,"Commodity",null,null,null,null,null,null,null,null,null,null,null,"% of Revenue",null,null,"Commodity",null,null,null,null,null,null,null,null,null,"% of Revenue"]
[]
[]
[]
[]
[]
[]
[null,null,"Summary of Total Loss Experience"]
[null,null,null,null,null,null,"Policy Effective Dates",null,null,null,null,"Total Claims Incurred (Paid and Reserved)",null,null,null,"# of Claims",null,"Premium",null,null,null,"Limits",null,null,"Ded/SIR Amount",null,null,"Insurer"]
[null,null,"Auto Liability",null,null,null,{"$f":"IF(OR($R$23=\"\",$T$14=\"\"),\"\",DATE(YEAR($T$14)-1,MONTH($T$14),DAY($T$14)))","v":""},null,"to",{"$f":"IF(OR($R$23=\"\",$T$14=\"\"),\"\",DATE(YEAR($T$14),MONTH($T$14),DAY($T$14)))","v":""}]
[null,null,null,null,null,null,{"$f":"IF(OR($R$23=\"\",$R$23=1,$T$14=\"\"),\"\",DATE(YEAR($T$14)-2,MONTH($T$14),DAY($T$14)))","v":""},null,"to",{"$f":"IF(OR($R$23=\"\",$R$23=1,$T$14=\"\"),\"\",DATE(YEAR($T$14)-1,MONTH($T$14),DAY($T$14)))","v":""}]
[null,null,null,null,null,null,{"$f":"IF(OR(AND($R$23<>3,$R$23<>\"4+\"),$T$14=\"\"),\"\",DATE(YEAR($T$14)-3,MONTH($T$14),DAY($T$14)))","v":""},null,"to",{"$f":"IF(OR(AND($R$23<>3,$R$23<>\"4+\"),$T$14=\"\"),\"\",DATE(YEAR($T$14)-2,MONTH($T$14),DAY($T$14)))","v":""}]
[null,null,null,null,null,null,{"$f":"IF(OR($R$23<>\"4+\",$T$14=\"\"),\"\",DATE(YEAR($T$14)-4,MONTH($T$14),DAY($T$14)))","v":""},null,"to",{"$f":"IF(OR($R$23<>\"4+\",$T$14=\"\"),\"\",DATE(YEAR($T$14)-3,MONTH($T$14),DAY($T$14)))","v":""}]
[null,null,"General Liability",null,null,null,{"$f":"$G154","v":""},null,"to",{"$f":"$J154","v":""}]
[null,null,null,null,null,null,{"$f":"$G155","v":""},null,"to",{"$f":"$J155","v":""}]
[null,null,null,null,null,null,{"$f":"$G156","v":""},null,"to",{"$f":"$J156","v":""}]
[null,null,null,null,null,null,{"$f":"$G157","v":""},null,"to",{"$f":"$J157","v":""}]
[null,null,"Owned Equipment",null,null,null,{"$f":"$G154","v":""},null,"to",{"$f":"$J154","v":""}]
[null,null,"Physical Damage",null,null,null,{"$f":"$G155","v":""},null,"to",{"$f":"$J155","v":""}]
[null,null,null,null,null,null,{"$f":"$G156","v":""},null,"to",{"$f":"$J156","v":""}]
[null,null,null,null,null,null,{"$f":"$G157","v":""},null,"to",{"$f":"$J157","v":""}]
[]
[null,null,"Provide details on all losses in excess of $50,000:"]
[]
[]
[]
[]
[]
[null,null,"Insurance Requested"]
[null,null,"Preferred Rating Basis (Check one):",null,null,null,null,null,null,null,null,"Revenue",null,null,null,"Mileage",null,null,null,"Per Unit"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"Deductible",null,null,null,null,null,"Limit"]
[null,null,"Auto Liability"]
[null,null,"Uninsured Motorists",null,null,null,null,null,null,null,null,"N/A"]
[null,null,"Underinsured Motorists",null,null,null,null,null,null,null,null,"N/A"]
[null,null,"Personal Injury Protection",null,null,null,null,null,null,null,null,"N/A"]
[null,null,"General Liability"]
[null,null,"Physical Damage"]
[null,null,"Trailer Interchange"]
[null,null,"Other (List Coverage below)"]
[]
[]
[]
[null,null,"Broker Comments (Other coverage options/target pricing):"]
[]
[]
[null,null,"Please list any state, province, or other filing requirements."]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"THIS APPLICATION CANNOT BE PROCESSED UNLESS SIGNED BY THE BROKER"]
[null,null,null,null,"AND AN AUTHORIZED OFFICER OF THE APPLICANT ORGANIZATI ON."]
[]
[null,null,null,null,"The Applicant hereby applies to the Company for a policy of insurance as set forth in this "]
[null,null,null,null,"application on the basis of statements contained here. Applicant agrees that such policy shall be "]
[null,null,null,null,"null and void if such information is materially false or misleading so that the Company would have "]
[null,null,null,null,"rejected the risk, prior to inception.  "]
[null,null,null,null,"Applicant understands that inquiries may be made which will provide applicable information concerning"]
[null,null,null,null,"the applicant’s business, financial stability and financial data, loss information and other information"]
[null,null,null,null,"which the Company deems relevant in order to determine whether the Company will accept or reject"]
[null,null,null,null,"applicant for coverage."]
[null,null,null,null,"Upon written request, additional information as to the nature and scope, if one is made, will be "]
[null,null,null,null,"pro vided.  The Applicant understands this application is a request for quotation and no "]
[null,null,null,null,"information provided herein shall be construed by either party as creating a binding contract for "]
[null,null,null,null,"insurance."]
[]
[null,null,null,null,"The undersigned authorized officer of the Applicant declares that the statements set forth herein "]
[null,null,null,null,"are true. The undersigned authorized officer agrees that if the information supplied on this "]
[null,null,null,null,"application changes between the date of this application and the effective date of the insurance , "]
[null,null,null,null,"he/she (undersigned) will, in order for"]
[null,null,null,null,"the information to be accurate on the effective date of the insurance, immediately notify the "]
[null,null,null,null,"Company of such changes, and the Company may withdraw or modify"]
[null,null,null,null,"any outstanding quotations and/or authorizations or agreements to bind the insurance."]
[]
[null,null,null,null,"Signing of this application does not bind the Applicant or the Company to complete the insurance, "]
[null,null,null,null,"but it is agreed that this application shall be the basis of the contract should a policy be "]
[null,null,null,null,"issued, and it will be attached to and become part of the policy."]
[]
[null,null,null,null,"All written statements and materials furnished to the Company in conjunction with this application "]
[null,null,null,null,"are hereby incorporated by reference into this application and made a part hereof."]
[]
[null,null,null,null,"Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents "]
[null,null,null,null,"a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents "]
[null,null,null,null,"false information in an application for insurance is guilty of a crime and may be subject to fines "]
[null,null,null,null,"and confinement in prison. *Applies in MD Only."]
[null,null,null,null,"Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or "]
[null,null,null,null,"information to an insurance company for the purpose of defrauding or"]
[null,null,null,null,"attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance "]
[null,null,null,null,"and civil damages. Any insurance company or agent of an insurance company who knowingly provides "]
[null,null,null,null,"false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose "]
[null,null,null,null,"of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or "]
[null,null,null,null,"award payable from insurance proceeds shall be reported t o the Colorado Division of Insurance "]
[null,null,null,null,"within the Department of Regulatory Agencies."]
[null,null,null,null,"Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive "]
[null,null,null,null,"any insurer files a statement of claim or an application containing any false, incomplete, or "]
[null,null,null,null,"misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only."]
[null,null,null,null,"Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be "]
[null,null,null,null,"presented or prepares with knowledge or belief that it will be presented to or by an insurer, "]
[null,null,null,null,"purported insurer, broker or any agent thereof, any written statement as part of, or in support "]
[null,null,null,null,"of, an application for the issuance of, or the rating of an insurance policy for personal or "]
[null,null,null,null,"commercial insurance, or a claim for payment or other benefit pursuant to a n insurance policy for "]
[null,null,null,null,"commercial or personal insurance which such person knows to contain materially false information "]
[null,null,null,null,"concerning any fact material thereto; or conceals, for the purpose of misleading, information "]
[null,null,null,null,"concerning any fact material thereto commits a fraudulent insurance act."]
[null,null,null,null,"Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance "]
[null,null,null,null,"company or other person files an application for insurance or statement of claim containing any "]
[null,null,null,null,"materially false information or conceals for the purpose of misleading, information concerning any "]
[null,null,null,null,"fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person "]
[null,null,null,null,"to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the "]
[null,null,null,null,"claim for each such violation)*. *Applies in NY Only."]
[null,null,null,null,"Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading "]
[null,null,null,null,"information to an insurance company for the purpose of"]
[null,null,null,null,"defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance "]
[null,null,null,null,"benefits. *Applies in ME Only."]
[null,null,null,null,"Applicable in NJ: Any person who includes any false or misleading information on an application for "]
[null,null,null,null,"an insurance policy is subject to criminal and civil penalties."]
[null,null,null,null," Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud"]
[null,null,null,null,"the insurer by submitting an application containing a false statement as to any material fact may be "]
[null,null,null,null,"violating state law."]
[null,null,null,null,"Applicable in PR: Any person who knowingly and with the intention of defrauding presents false "]
[null,null,null,null,"information in an insurance application, or presents, helps, or causes the presentation of a "]
[null,null,null,null,"fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim "]
[null,null,null,null,"for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for "]
[null,null,null,null,"each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten "]
[null,null,null,null,"thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. "]
[null,null,null,null,"Should aggravating circumstances [be] present, the penalty thus established may be increased to a "]
[null,null,null,null,"maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum "]
[null,null,null,null,"of two (2) years."]
[]
[]
[null,null,null,"THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE "]
[null,null,null,"INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS"]
[null,null,null,"THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE."]
[null,null,"APPLICANT'S SIGNATURE",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DATE"]
[]
[]
[]
[null,null,"Applicant's Name (Please Print)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Applicant's Title"]
[]
[null,null,"TO BE COMPLETED BY THE PRODUCER"]
[null,null,"Producer(s)",null,null,{"$f":"IF(U11=\"\",\"\",U11)","v":""},null,null,null,null,null,null,null,"Are you the incumbent broker?",null,null,null,null,null,null,null,null,null,"If Yes, how many years?"]
[]
[null,null,"Is the business of the Applicant direct business of your office? ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If no, explain:"]
[]
[null,null,"Have you read the answers given by the Applicant above?"]
[]
[null,null,"Are the answers given by the Applicant above correct to the best of your knowledge?"]
[]
[null,null,"How long have you known the Applicant or, if the Applicant is a corporation, the officers and directors of Applicant?"]
[]
[null,null,"PRODUCER'S SIGNATURE",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DATE"]
[]
[]
[]
[null,null,"PRODUCER'S NAME (Please Print)",null,null,null,null,null,null,null,null,null,null,null,null,null,"STATE PRODUCER LICENSE NO",null,null,null,null,null,"NATIONAL PRODUCER NUMBER"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(Required in Florida)"]

{"sheet":"Vehicle Schedule","index":1,"n_rows":2000,"n_cols":7,"rows_kept":2000,"cut":false,"hidden":false,"merged":[]}
["Vehicle #","Year","Make","Type","VIN","GVWR","Stated Amount"]
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
[72]
[73]
[74]
[75]
[76]
[77]
[78]
[79]
[80]
[81]
[82]
[83]
[84]
[85]
[86]
[87]
[88]
[89]
[90]
[91]
[92]
[93]
[94]
[95]
[96]
[97]
[98]
[99]
[100]
[101]
[102]
[103]
[104]
[105]
[106]
[107]
[108]
[109]
[110]
[111]
[112]
[113]
[114]
[115]
[116]
[117]
[118]
[119]
[120]
[121]
[122]
[123]
[124]
[125]
[126]
[127]
[128]
[129]
[130]
[131]
[132]
[133]
[134]
[135]
[136]
[137]
[138]
[139]
[140]
[141]
[142]
[143]
[144]
[145]
[146]
[147]
[148]
[149]
[150]
[151]
[152]
[153]
[154]
[155]
[156]
[157]
[158]
[159]
[160]
[161]
[162]
[163]
[164]
[165]
[166]
[167]
[168]
[169]
[170]
[171]
[172]
[173]
[174]
[175]
[176]
[177]
[178]
[179]
[180]
[181]
[182]
[183]
[184]
[185]
[186]
[187]
[188]
[189]
[190]
[191]
[192]
[193]
[194]
[195]
[196]
[197]
[198]
[199]
[200]
[201]
[202]
[203]
[204]
[205]
[206]
[207]
[208]
[209]
[210]
[211]
[212]
[213]
[214]
[215]
[216]
[217]
[218]
[219]
[220]
[221]
[222]
[223]
[224]
[225]
[226]
[227]
[228]
[229]
[230]
[231]
[232]
[233]
[234]
[235]
[236]
[237]
[238]
[239]
[240]
[241]
[242]
[243]
[244]
[245]
[246]
[247]
[248]
[249]
[250]
[251]
[252]
[253]
[254]
[255]
[256]
[257]
[258]
[259]
[260]
[261]
[262]
[263]
[264]
[265]
[266]
[267]
[268]
[269]
[270]
[271]
[272]
[273]
[274]
[275]
[276]
[277]
[278]
[279]
[280]
[281]
[282]
[283]
[284]
[285]
[286]
[287]
[288]
[289]
[290]
[291]
[292]
[293]
[294]
[295]
[296]
[297]
[298]
[299]
[300]
[301]
[302]
[303]
[304]
[305]
[306]
[307]
[308]
[309]
[310]
[311]
[312]
[313]
[314]
[315]
[316]
[317]
[318]
[319]
[320]
[321]
[322]
[323]
[324]
[325]
[326]
[327]
[328]
[329]
[330]
[331]
[332]
[333]
[334]
[335]
[336]
[337]
[338]
[339]
[340]
[341]
[342]
[343]
[344]
[345]
[346]
[347]
[348]
[349]
[350]
[351]
[352]
[353]
[354]
[355]
[356]
[357]
[358]
[359]
[360]
[361]
[362]
[363]
[364]
[365]
[366]
[367]
[368]
[369]
[370]
[371]
[372]
[373]
[374]
[375]
[376]
[377]
[378]
[379]
[380]
[381]
[382]
[383]
[384]
[385]
[386]
[387]
[388]
[389]
[390]
[391]
[392]
[393]
[394]
[395]
[396]
[397]
[398]
[399]
[400]
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[404]
[405]
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[410]
[411]
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[529]
[530]
[531]
[532]
[533]
[534]
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[537]
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[549]
[550]
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[552]
[553]
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[557]
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[564]
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[566]
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[569]
[570]
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[609]
[610]
[611]
[612]
[613]
[614]
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[629]
[630]
[631]
[632]
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[707]
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[715]
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[721]
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[724]
[725]
[726]
[727]
[728]
[729]
[730]
[731]
[732]
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[734]
[735]
[736]
[737]
[738]
[739]
[740]
[741]
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[743]
[744]
[745]
[746]
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[749]
[750]
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[764]
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[769]
[770]
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[780]
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[789]
[790]
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[792]
[793]
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[795]
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[797]
[798]
[799]
[800]
[801]
[802]
[803]
[804]
[805]
[806]
[807]
[808]
[809]
[810]
[811]
[812]
[813]
[814]
[815]
[816]
[817]
[818]
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[820]
[821]
[822]
[823]
[824]
[825]
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[827]
[828]
[829]
[830]
[831]
[832]
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[834]
[835]
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[837]
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[839]
[840]
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[842]
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[844]
[845]
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[849]
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[859]
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[861]
[862]
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[865]
[866]
[867]
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[870]
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[1009]
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[1020]
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[1120]
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[1125]
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[1128]
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[1130]
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[1900]
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[1914]
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[1930]
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[1932]
[1933]
[1934]
[1935]
[1936]
[1937]
[1938]
[1939]
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[1941]
[1942]
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[1944]
[1945]
[1946]
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[1948]
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[1950]
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[1953]
[1954]
[1955]
[1956]
[1957]
[1958]
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[1960]
[1961]
[1962]
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[1964]
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[1980]
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[1983]
[1984]
[1985]
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[1988]
[1989]
[1990]
[1991]
[1992]
[1993]
[1994]
[1995]
[1996]
[1997]
[1998]
[1999]

{"sheet":"Driver Schedule","index":2,"n_rows":1000,"n_cols":9,"rows_kept":1000,"cut":false,"hidden":false,"merged":[]}
["#","First Name","Last Name","DOB","License #","State","CDL Experience","DOH","Fulltime/Part Time"]
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
[72]
[73]
[74]
[75]
[76]
[77]
[78]
[79]
[80]
[81]
[82]
[83]
[84]
[85]
[86]
[87]
[88]
[89]
[90]
[91]
[92]
[93]
[94]
[95]
[96]
[97]
[98]
[99]
[100]
[101]
[102]
[103]
[104]
[105]
[106]
[107]
[108]
[109]
[110]
[111]
[112]
[113]
[114]
[115]
[116]
[117]
[118]
[119]
[120]
[121]
[122]
[123]
[124]
[125]
[126]
[127]
[128]
[129]
[130]
[131]
[132]
[133]
[134]
[135]
[136]
[137]
[138]
[139]
[140]
[141]
[142]
[143]
[144]
[145]
[146]
[147]
[148]
[149]
[150]
[151]
[152]
[153]
[154]
[155]
[156]
[157]
[158]
[159]
[160]
[161]
[162]
[163]
[164]
[165]
[166]
[167]
[168]
[169]
[170]
[171]
[172]
[173]
[174]
[175]
[176]
[177]
[178]
[179]
[180]
[181]
[182]
[183]
[184]
[185]
[186]
[187]
[188]
[189]
[190]
[191]
[192]
[193]
[194]
[195]
[196]
[197]
[198]
[199]
[200]
[201]
[202]
[203]
[204]
[205]
[206]
[207]
[208]
[209]
[210]
[211]
[212]
[213]
[214]
[215]
[216]
[217]
[218]
[219]
[220]
[221]
[222]
[223]
[224]
[225]
[226]
[227]
[228]
[229]
[230]
[231]
[232]
[233]
[234]
[235]
[236]
[237]
[238]
[239]
[240]
[241]
[242]
[243]
[244]
[245]
[246]
[247]
[248]
[249]
[250]
[251]
[252]
[253]
[254]
[255]
[256]
[257]
[258]
[259]
[260]
[261]
[262]
[263]
[264]
[265]
[266]
[267]
[268]
[269]
[270]
[271]
[272]
[273]
[274]
[275]
[276]
[277]
[278]
[279]
[280]
[281]
[282]
[283]
[284]
[285]
[286]
[287]
[288]
[289]
[290]
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[292]
[293]
[294]
[295]
[296]
[297]
[298]
[299]
[300]
[301]
[302]
[303]
[304]
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[308]
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[314]
[315]
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[319]
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[322]
[323]
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[335]
[336]
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[338]
[339]
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[343]
[344]
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[346]
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[349]
[350]
[351]
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[365]
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[375]
[376]
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[381]
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[386]
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[390]
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[392]
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[518]
[519]
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[524]
[525]
[526]
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[529]
[530]
[531]
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[541]
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[563]
[564]
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[566]
[567]
[568]
[569]
[570]
[571]
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[579]
[580]
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[599]
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[601]
[602]
[603]
[604]
[605]
[606]
[607]
[608]
[609]
[610]
[611]
[612]
[613]
[614]
[615]
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{"sheet":"Lists","index":3,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":true,"merged":[]}
["States",null,null,null,"Vehicle Types",null,null,"GVWR",null,null,null,"Years"]
["Alabama",null,null,null,"Tractor",null,null,"0 - 10,000 lbs",null,null,null,1]
["Alaska",null,null,null,"Trailer",null,null,"10,001 - 20,000 lbs",null,null,null,2]
["Arizona",null,null,null,"Straight Truck",null,null,"20,001 - 45,000 lbs",null,null,null,3]
["Arkansas",null,null,null,"Service Truck",null,null,"45,000 + lbs",null,null,null,"4+"]
["California",null,null,null,"PPV"]
["Colorado"]
["Connecticut"]
["DC"]
["Delaware"]
["Florida"]
["Georgia"]
["Hawaii"]
["Idaho"]
["Illinois"]
["Indiana"]
["Iowa"]
["Kansas"]
["Kentucky"]
["Louisiana"]
["Maine"]
["Maryland"]
["Massachusetts"]
["Michigan"]
["Minnesota"]
["Mississippi"]
["Missouri"]
["Montana"]
["Nebraska"]
["Nevada"]
["New Hampshire"]
["New Jersey"]
["New Mexico"]
["New York"]
["North Carolina"]
["North Dakota"]
["Ohio"]
["Oklahoma"]
["Oregon"]
["Pennsylvania"]
["Rhode Island"]
["South Carolina"]
["South Dakota"]
["Tennessee"]
["Texas"]
["Utah"]
["Vermont"]
["Virginia"]
["Washington"]
["West Virginia"]
["Wisconsin"]
["Wyoming"]