Submission Checklist and Application

Submission Checklist Motor Truck Physical Damage and Cargo

AIG Fleet Application

AIG Motor Carrier Application

AIFE Fleet Application

Berkley Small Trucking Questionnaire

Freberg / Arch - Hazmat Program Application

Freberg / Arch - New Venture Application

Adriatic Cargo Application

Adriatic Physical Damage Application

Crum & Forster Occ/Acc & CL Application

Great American Cargo Application

Lloyds of London - Cargo

Lloyds of London - Terrorism

Truckers Physical Damage Application

Zurich Occupational Accident Group Application (10+ lives)

Zurich Contingent Liability Application (Occupational Accident)

Zurich Non-truck Liability and Physical Damage

Zurich Workers Compensation Supplement (only available in conjunction with Occupational Accident and Contingent Liability)

Zurich Passenger Accident

Pan American Life Insurance Company’s Occ/Acc Guidelines with Plans A, B, C and Z Enrollment Forms

- State-specific carrier enrollment forms are also required, where applicable.

- Coverage is with an admitted carrier. No need for surplus lines taxes or affidavits.

- New enrollment questionnaire and enrollment forms are required. We are not able to accept our prior enrollment forms.

• GUIDELINES
• EQABC 06 2019 – ENROLLEE QUESTIONNAIRE FOR PLANS A, B, AND C – COLLECTION OF UNDERWRITING INFORMATION
• EQZ 06 2019 – ENROLLEE QUESTIONNAIRE FOR PLAN Z – COLLECTION OF UNDERWRITING INFORMATION
• ALABAMA ENROLLMENT FORM
• CALIFORNIA ENROLLMENT FORM
• FLORIDA ENROLLMENT FORM (USE FOR THE STATES CT, FL, GA, NJ, OH, PA, WI)
• IOWA ENROLLMENT FORM
• ILLINOIS ENROLLMENT FORM
• INDIANA ENROLLMENT FORM
• KENTUCKY ENROLLMENT FORM
• OKLAHOMA ENROLLMENT FORM
• TENNESSEE ENROLLMENT FORM

- If you have a driver located in a state other than the states listed in our underwriting guidelines, please contact your underwriter or email us at occacc@5starsp.com.