← Back to Forms New Business Application You can start your application for insurance here. 1Who Is Being Insured2Contact & Business Information3Business Documentation4Lines of Service5Additional Information6Hiring Practices & Safety7Revenue8Auto & Warehousing9General Liability10Property11Workers Compensation12Crime13Cyber Liability Please complete any relevant sections of this application.Who Is Being Insured?Effective Date MM slash DD slash YYYY When does your insurance need to start?Primary Named Insured 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 Phone #Email Contact & Business InformationContact Person First Last Title Website Address Federal Employer ID # # of Years In BusinessPlease enter a number greater than or equal to 0.Van Line Affiliation # of Full Time EmployeesPlease enter a number greater than or equal to 0.# of Part Time EmployeesPlease enter a number greater than or equal to 0.Total EmployeesAdditional Named InsuredsName / AddressDescription of Function (Holding Company, Moving Company, Property Owner, etc.)Owner's Name% of Ownership Add Remove Business DocumentationPlease provide the following, if applicable: Copies of Current Loss Runs for all lines of coverage for 5 years – current year plus 4 previous years (Explain losses over $25,000) Copies of the following policy declaration pages indicating limits for the coverage you are requesting and any subsequent endorsements/changes after policy inception date. Automobile Crime Umbrella Property Warehouse & Cargo Other General Liability Workers Compensation Financials Copy of all current filings (Federal, State, Military (SCAC) and DD2787) A copy of your Bill of Lading and/or Warehouse Receipt Copy of Written Procedures for Safety Program Copies of Van Line Contracts Attach Documents Drop files here or Select files Max. file size: 100 MB. Lines of ServiceDo you conduct any of the following services? Crating Retail Stores Equipment Rental Rigging Furniture / Fixture Installation Appliance Installation Auto / Vehicle Repair Select AllProvide details of service conducted: Crating Provide details of service conducted: Retail Stores Provide details of service conducted: Equipment Rental Provide details of service conducted: Rigging Provide details of service conducted: Furniture / Fixture Installation Provide details of service conducted: Appliance Installation Provide details of service conducted: Auto / Vehicle Repair Additional InformationAre you a subsidiary of another entity or do you have any subsidiaries? Yes No Please explain: Do you use contract drivers or owner/operators? Yes No Are contract drivers/owner operators scheduled on the policy? Yes No Do they haul exclusively for you? Yes No Does anyone other than your company own any scheduled vehicles? Yes No Please explain: Do you issue a Bill of Lading or other Contract on All Moves? Yes No Please explain: Hiring PracticesDo you lease employees from an employee leasing firm? Yes No Attach a copy of the leasing agreementMax. file size: 100 MB.Is there a formal applicant screening process? Yes No Are there written job descriptions with minimum qualifications? Yes No Are experience and qualifications verified for each new hire? Yes No Are demonstrations of “critical skills” required prior to hiring? Yes No Do you obtain & review MVR’s prior to hiring? Yes No Do you have a formal written safety program? Yes No Is there a written vehicle maintenance program? Yes No Check items that your vehicle maintenance maintenance plan includes: Regular Preventive Maintenance Certified Mechanics Safety & Pre-Trip Inspections Do you have any 409 agreements (military contracts)? Yes No Do you provide binding quotes over the Internet? Yes No Do you need an UIIA endorsement? Yes No RevenueLinehaul Projected for Next YearOwn Authority (0 - 100 miles)Own Authority (101 - 300 miles)Own Authority (300+ miles)Van Line Authority (0 - 100 miles)Van Line Authority (101 - 300 miles)Van Line Authority (300+ miles)Linehaul Current YearOwn Authority (0 - 100 miles)Own Authority (101 - 300 miles)Own Authority (300+ miles)Van Line Authority (0 - 100 miles)Van Line Authority (101 - 300 miles)Van Line Authority (300+ miles)Storage Projected Total AutoCurrent Drivers ListMax. file size: 100 MB.Current Vehicle ScheduleMax. file size: 100 MB.Copies of Vehicle Registration (for NY & GA) Drop files here or Select files Max. file size: 100 MB. List of Lienholders for each Vehicle Drop files here or Select files Max. file size: 100 MB. Cargo / WarehouseHow are items stored?% VaultsPlease enter a number from 0 to 100.How high are your vaults stacked? 1 high 2 high 3 high % RacksPlease enter a number from 0 to 100.% LoosePlease enter a number from 0 to 100.% UnusedPlease enter a number from 0 to 100.% Total# of pounds currently in storage for Government Non-Temp# of government pounds in storageGovernment Storage Limit $# of civilian pounds in storageCivilian Storage Limit $Any PODS? Yes No Any Exhibition / Trade Shows? Yes No Provide details Do you own any mini-storage facilities? Yes No Provide details Do you store any Goods of Others in a mini-storage facility not owned by you? Yes No Provide details Please attach a list of forklifts, special contracts Drop files here or Select files Max. file size: 100 MB. General LiabilityAnnual Warehouseman's / Packers Payroll# of FT# of PTOther Exposures (case-by-case basis) Add Remove PropertyDetailsAddressBuilding / LimitContents LimitBusiness Income with Extra Expense LimitConstruction TypeSquare Footage WarehouseSquare Footage OfficeYear BuiltUpdates (roof, wiring, plumbing, heating)SprinkleredFire/Central StationBurglar/Central StationLeased/Owned?If leased, sq. ft.Do you have Outdoor Signs / Scales? Add Remove Workers CompensationWhat is your latest Experience Modification?Please provide a copy of the latest worksheetMax. file size: 100 MB.Annual Payroll for:8293 Drivers/Helpers8810 Clerical8742 SalesList any other applicable class codes you useClass CodeAnnual Payroll Add RemoveOfficersOfficer NameTitleIf including for Workers Compensation Coverage, provide payroll Add Remove CrimeAre all incoming checks stamped “For Deposit Only” as soon as they are received? Yes No Are all company accounts reconciled against a job or customer each month? Yes No Are drivers required to present receipts for fuel or others services daily with their bill of lading? Yes No Is the purchase of company supplies, packing materials, equipment etc. handled through a purchase order process that requires not only an employee signature but also a signature of the general manager or controller? Yes No Are fuel cards limited to a single vendor and provided to drivers with caution? Yes No Do fuel cards require a PIN number for use? Yes No Do you verify transfer instructions purportedly issued by you, an employee, or other management and staff, your vendors and your customers? Yes No All instructions are verifiable Instructions are verified for transfers instructions in excess of a certain amount. Instructions are verified for all transfer instructions in excess of Cyber LiabilityPlease indicate your desired limit of cyber insurance $100,000 $250,000 $500,000 $1,000,000 Please indicate the type(s) of personally identifiable information ("PII") that the organization may collect, use and/or disclose on employees, members, volunteers or others Social Security # Credit/Payment Card Data Tax Data Personal Health Info Bank/Financial Account Data Drivers/State Identification Does the organization maintain computer security that includes a) firewall, b) anti-virus, c) spy- ware /malware protection, and d) access controls that include passwords? Yes No Has the organization experienced any loss, theft or breach of personal information in the past three years? Yes No Additional explanation you would like to provide regarding the questions contained in this application.Interested in any other coverages not listed here? Feel free to let us know below!