Household Goods Mover's/Carrier's Legal Liability and

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HANOVER MOVING AND STORAGE ADVANTAGE

Household Goods Mover’s/Carrier’s Legal Liability and Warehouseman’s

Legal Liability Application and Supplemental Questionnaire

APPLICANT’S INFORMATION

First Named Insured: ___________________________________________________________________________________________________________

Mailing Address:_______________________________________________________________________________________________________________

Other Named Insureds: ________________________________________________________________________________________________________

(including nature of operations and named insured interest for each):

Website Address: ______________________________________________________________________________________________________________

Affiliation with a National Van Line?: Yes No

If Yes, with whom: _____________________________________________________________________________________________________________

When hauling under National Van Line’s Authority, is the National Van Line responsible for the following:

Automobile Liability Yes No

Workers’ Compensation Yes No

Cargo Yes No

General Liability Yes No

Does National Van Line require additional insured status? Yes No

UNDERWRITING INFORMATION

1. Do you possess your own Interstate Authority? Yes No

If Yes, under what name: ___________________________________________________________________________________________________

Under what address: _______________________________________________________________________________________________________

FMSCA Docket Number: ___________________________________________________________________________________________________

What states do you hold authority? __________________________________________________________________________________________

Furthest distance travelled under own authority? ______________________________________________________________________________

Provide DPU or PUC number for each state (for filing purposes)

State Number

_______________________________________________________ ______________________________________________________________

2. Are you affiliated with or have membership in any Trade Association? Yes No

If Yes, please list: __________________________________________________________________________________________________________

Are you ISO 9000 or 9001 certified? Yes No Enrolled? Yes No

3. Do you issue a Bill of Lading on all moves? Yes No

4. Do you currently offer direct damage or “Certificates” of Insurance to your customers? Yes No

Transit _______________________ Storage ___________________________

What is your total outstanding limit on storage certificates? ____________________________________________________________________

What is the total number of existing certificates from your current carrier? _______________________________________________________

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5. Revenue Sources Period: ____________ to ____________

CATEGORY AMOUNT OF

REVENUE

% UNDER YOUR

AUTHORITY OR

CONTRACT

% UNDER VAN LINE

OR OTHER’S

OPERATING

AUTHORITY

ANNUAL MILEAGE

Line Haul

Local Hauling

Intra-State Hauling

Inter-State Hauling

Military Shipments

General Freight Haul

Ofce and Industrial

Packing

Permanent Storage

Valuation Charges

Packing Materials

Mini/Self Storage

Container Rental

Booking Commissions

Other (describe)

________________________________

Total Revenue

6. Operations History 1st Prior Year 2nd Prior Year 3rd Prior Year

Total # Power Units _______________________ ________________________ ________________________

Total Annual Revenue _______________________ ________________________ ________________________

Total Annual Mileage _______________________ ________________________ ________________________

Furthest distance travelled: City/State _______________________________________________________________________________________

7. Do you perform any rigging, use hoists or cranes? Yes No

Do you install furniture, appliances, or equipment? Yes No

Do you operate an auto/truck repair facility? Yes No

Are repairs performed for other than owned vehicles? Yes No

Do you perform furniture repair? Yes No

Is public access to your warehouse premises permitted? Yes No

Do you utilize subcontractors for any operation? Yes No

Do you secure Certificates of Insurance from subcontractors? Yes No

Who reviews the Certificates of Insurance? ________________________________________________________________________________

Are hold harmless in favor of applicant used? Yes No

Is Additional Insured status required? Yes No

Do Others Name you as an additional insured? Yes No

Are you required to name others as additional insured? Yes No

Do you perform background checks on employees? Yes No

Do you require your subcontractors to perform background checks? Yes No

Does top management review all contracts entered? Yes No

Do you ever use Lumpers when performing a move? Yes No

$ 0

8. Describe the process used for qualifying your drivers: _________________________________________________________________________

Do you require annual driver recertification and training? Yes No

Describe the program you use: _____________________________________________________________________________________________

How frequently do you check your driver’s motor vehicle records? ______________________________________________________________

Describe your driver acceptability criteria: ___________________________________________________________________________________

Do you utilize the FMCSA safety database for screening driver applicants? Yes No

Do you utilize Independent Owner Operators? Yes No

Are all Owner Operators contracted and exclusively hauling for you? Yes No

Are Owner Operators whom you use contracted with your National Van Line? Yes No

Length of time and number of owner operators working for you. < 1 year _____ 1 to 3 years _____ > 3 years _____

Do you require O/O to carry auto coverage? Yes No

Do you require O/O to carry workers’ comp coverage? Yes No

Do you require O/O to carry cargo coverage? Yes No

Do you engage in trip leasing? Yes No

Do you utilize common or contract carriers to support your operations in any way? Yes No

Do you have a written trailer interchange agreement? Yes No

Do you ever pull a non-owned trailer outside a written trailer interchange agreement? Yes No

9. Technology used in your vehicle operations:

Automated Logs Yes No All _______%

GPS Locator/Tracking Yes No All _______%

Dash Cameras Yes No All _______%

Lane Change Warning Indicators Yes No All _______%

Collision Avoidance Yes No All _______%

Fleet Safety program in place? Yes No

If Yes, attach a copy of the program.

What steps are taken after an accident has occurred?

Details:

_________________________________________________________________________________________________________________________

10. Do you do Government Non-Temp Storage? Yes No

Percentage of non-household goods stored on premises ______%

Nature of non-household goods stored: _____________________________________________________________________________________

Number of Eviction Moves performed annually? ______________

11. The following information is to be attached to completed ACORD applications:

List of all drivers including date of birth, license number, state of license, date of hire, and indicate if driver has a Commercial Driver’s

License. Include current MVRs if available. Minimum 3 plus the current year hard copy currently valued company loss runs. Copies of

owner-operator agreements, National Van Lines agreement, Bill of Lading, Warehouse Receipt, Record Storage Contractor Receipt,

Financial Statements (most recent accountant prepared), and quarterly road tax filings.

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SUPPLEMENTAL DECLARATIONS

1. CARRIER’S LEGAL LIABILITY

Limit per Vehicle $ __________________________

Limit per Terminal described in the Declarations $ __________________________

Two or More Vehicles Away from Premises $ __________________________

Storage in Transit at Unnamed Locations $ __________________________

Freight Forwarding-Limit per Vehicle-Common/Contract Carrier $ __________________________

Air Carrier $ __________________________

Railroad $ __________________________

Unnamed Terminal $ __________________________

Deductible $ __________________________

2. WAREHOUSEMAN’S LEGAL LIABILITY/BAILEES LIABILITY

Limit per Location described in the Declarations $ __________________________

Internal Moves at Unnamed Locations $ __________________________

Rigging $ __________________________

Deductible $ __________________________

3. MOVING EQUIPMENT & MISCELLANEOUS PROPERTY

Limit of Insurance $ __________________________

Deductible $ __________________________

4. CUSTOMERS COVERAGES — TRANSIT AND STORAGE

In Transportation — Any One Customer $ __________________________

In Storage — Any One Customer $ __________________________

In Storage — Aggregate $ __________________________

Deductible $ __________________________

5. CARRIER’S INCOME PROTECTION

Linehaul and Related Charges $ __________________________

Linehaul and Related Charges Deductible $ __________________________

Uncollectible Storage and Related Charges $ __________________________

Loss of Business Income $ __________________________

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All products are underwritten by The Hanover Insurance Company or one of its insurance company subsidiaries or afliates (“The Hanover”). Coverage may not be available in all jurisdictions

and is subject to the company underwriting guidelines and the issued policy. This material is provided for informational purposes only and does not provide any coverage. For more

information about The Hanover visit our website at www.hanover.com

The Hanover Insurance Company

440 Lincoln Street, Worcester, MA 01653

hanover.com

The Agency Place (TAP) — https://tap.hanover.com

117-1062 (12/20)

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SCHEDULE OF LOCATIONS/TERMINALS

Location No. 1 ________________________________________________________________________________________________________________

Location No. 2 ________________________________________________________________________________________________________________

Location No. 3 ________________________________________________________________________________________________________________

Location No. 4 ________________________________________________________________________________________________________________

Location No. 5 ________________________________________________________________________________________________________________

Location No. 6 ________________________________________________________________________________________________________________

Location No. 7 ________________________________________________________________________________________________________________

Location No. 8 ________________________________________________________________________________________________________________

Location No. 9 ________________________________________________________________________________________________________________

OTHER

Please explain further or clarify answers to any questions you feel are necessary.

Applicant Agent

Name: ____________________________________________________ Name: ____________________________________________________

Position: __________________________________________________ Position: __________________________________________________

Signature: _________________________________________________ Signature: _________________________________________________

Date: _____________________________________________________ Date: _____________________________________________________