ONLINE CONTINGENT AUTO LIABILITY APPLICATION
NOTE: CONTINGENT AUTO LIABILITY INSURANCE IS SECONDARY TO THE MOTOR CARRIERS AUTO POLICY
 
About Your Brokerage
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Applicant:

ICC Brokerage MC #:
Are You A Freight Forwarder?     If yes, provide FF number 
Contact Name:
Mailing Address:
Telephone:
Fax:
Email Address:
Proposed Effective Date:
How Many Years in Business:
Have you ever had Contingent Auto Liability Insurance?
If so, with whom?
In the past 3 years, have you been named in any lawsuit?
If lawsuit, please explain:
In the past 3 years, have any claims been paid on your behalf?
If claims paid on your behalf, please explain:
 

 
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