BOX TRUCK

INSURANCE REQUIREMENTS CHECKLIST

All insurance policies must be written with insurance carriers who have a current A.M. Best rating of “A-
VII” or higher

The identification number assigned to each insurer by the National Association of Insurance Commissioners
must be listed on each insurance policy.

All certificates of insurance must reference the actual policy numbers assigned by the insurers; binder
numbers are not sufficient.

The certificate of insurance must be in the form of an ACORD 25 (2010/05) version or newer.

The certificate must be current dated and signed by an Authorized Representative.

General Liability
• $1,000,000 Occurrence Limit, $2,000,000 General Aggregate Limit and $1,000,000 Products and Completed
Operations Aggregate Limit
• At a minimum, the policy must be rated pursuant to ISO Class Code 91155, “Appliance and Accessories –
Installation, Servicing or Repair”, or its equivalent

Auto Liability
• $1,000,000 Combined Single Limit
• Coverage must be provided on an Any Auto, or combination of Scheduled, Hired and Non-Owned basis.
• NOTE: Each Scheduled vehicle(s) VIN must be listed on certificate.

Motor Truck Cargo

• $50,000 Per Occurrence Limit

Work Injury Coverage

• Coverage must apply to all employees or helpers/workers.
• Workers Compensation policy - Statutory Limits
• Workers Compensation policy - Employers Liability Limits: $500,000 Each Accident, $500,000
Disease – Policy Limit, $500,000 Disease – Each Employee
• NOTE: Workers Compensation policy – If any Owner, Partner, Officer or Member is excluded, they
must sign the Hold Harmless Agreement in favor of Pilot Freight Services. If Officer drives, they are
required to obtain Occupational Accident & Contingent Liability.
• Occupational Accident policy – Must include helper/worker coverage.
• NOTE: If Occupational Accident is obtained, Contingent Liability coverage must also be obtained.
• Contingent Liability insurance with limits equal to the statutory Workers Compensation limits in all
states must be obtained. Coverage must extend to include all individuals covered by the Occupational

Rev. 05/24/22
 Accident policy, including, but not limited to any proprietor, partner or corporate officer of the Small
Trucking Firm and all of the drivers and helpers of the Small Trucking Firm.

Certificate Holder
Pilot Air Freight, LLC DBA Pilot Freight Services
c/o TrueNorth - Compliance
PO Box 1863
Cedar Rapids, IA 52406-1863

Rev. 05/24/22
 CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)

MM/DD/YYYY
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Insurance Agent Contact
PHONE FAX
Agency Name (A/C, No, Ext): Insurance Agent Phone Number (A/C, No):
E-MAIL
Street Address ADDRESS: Insurance Agent Email

City State Zip INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : A- VII Rated Insurance Company #####

INSURED INSURER B :

Motor Carrier Business Name INSURER C :

Street Address INSURER D :

City State Zip INSURER E :

INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

E
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS

A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000

Policy Number MM/DD/YYYY MM/DD/YYYY DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

PRO-
PL MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

$

$
$
2,000,000
1,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A (Ea accident) $ 1,000,000
Policy Number MM/DD/YYYY MM/DD/YYYY
BODILY INJURY (Per person) $
ANY AUTO
M
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB
SA

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $
WORKERS COMPENSATION WC STATU- OTH-
A TORY LIMITS ER
AND EMPLOYERS' LIABILITY Y/N Policy Number MM/DD/YYYY MM/DD/YYYY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? N
N/A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
A Motor Truck Cargo Policy Number MM/DD/YYYY MM/DD/YYYY Limit $50,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

Pilot Air Freight, LLC DBA Pilot Freight Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
c/o TrueNorth - Compliance ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 1863
Cedar Rapids, IA 52406-1863 AUTHORIZED REPRESENTATIVE

Insurance Agent Signature

© 1988-2010 ACORD CORPORATION. All rights reserved.

ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD