Western Transportation Insurance Services, Inc.

205 Natoma Street, Folsom, CA 95630
(916) 355-1300 • (800) 391-1313 • Fax (916) 355-1306

Type of Ownership

Individual Partner Corp

Authority

Contract Carrier Common Carrier

DOT Safety Rating:

Garage Address:

City/State/Zip:

Years in Business:

Years Experience:

Commodity Hauled (Percentage):

Routes of Travel (Major Cities and Percentage):

Gross Receipts:

Current Est.	Year 1
Year 2	Year 3

Subhaul Exposure:

Yes No
If yes, cost of hire

*Coverages:*
LIA: GL: Phys., Dam., Ded.: CARGO $: DED $: Reefer B/D:YesNo Average Cargo Limit: Type of Reefer Unit: When Serviced:

Previous Carriers and Experience:

Vehicle Maintenance Program:

Show % of Trips:

0 to 75 miles:

76 to 150 miles:

151 to 300 miles:

301 to 500 miles:

For trips over 500 miles, select the states you travel in and indicate the percentage of trips into each zone
Zone 01:	CT DE ME MD MA NH NJ NY RI VT
Zone 02:	AL CA FL GA IL IN MI NC OH PA SC VA WV
Zone 03:	AZ AR KY LA MN MS MO OK OR TN TX WA WI
Zone 04:	CO ID IA KS MT NE NV NM ND SD UT WY

Schedule of Equipment:

LOSS PAYEE, CERTIFICATE HOLDERS AND ADDITIONAL INSUREDS

Loss Payee Certificate Holder Additional Insured
UNIT #
NAME
ADDRESS

FAX #

Loss Payee Certificate Holder Additional Insured
UNIT #
NAME
ADDRESS

FAX #

Loss Payee Certificate Holder Additional Insured
UNIT #
NAME
ADDRESS

FAX #

Loss Payee Certificate Holder Additional Insured
UNIT #
NAME
ADDRESS

FAX #

Drivers:

New Venture - Must be completed if three years prior carrier information is not supplied.

Comments/Loss Explanations: