Delivery Application Form

Who is your Founder Shield contact (if applicable)

1. Name of Insured*

The legal name of the insured

2. Address of Insured*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Revenue, Deliveries & Miles

Questions 3-5 refer to the total (past and projected) revenue, deliveries and miles attributed to deliveries via your platform broken out by cities and years. If you serve more than 5 cities or have this data readily available in a spreadsheet, please upload the spreadsheet below. Otherwise, fill out the questions and click the + sign to add additional rows.

Upload Spreadsheet

Drop files here or

Max. file size: 32 MB.

3. Receipts/revenues arising from Deliveries for last 5 years and projected for the coming 5 years (or as far as is possible).

Year	Revenue

4. Total miles driven on the platform, split out by city/state and month for the last 5 years and projected for the coming 5 years (or as far as is possible).

Month/Year	City, State	Miles

5. Total deliveries made, split out by city/state and month for the last 5 years and projected for the coming 5 years (or as far as is possible

Year/Month	City, State	Deliveries

6. Details of types of items delivered (for example perishables, fast food, mail, clothes)*

7. Can alcoholic beverages, tobacco or marijuana be delivered through the platform?*

Yes
No

9. Please confirm there is no carriage of people?*

Yes
No

7.1 What controls are in place to ensure the customer is of the legal age?*

8. When performing the above operations, are there timeframes that the applicant commits to?*

Yes
No

8.1 Please provide details*

10. Number of employees performing deliveries*

Number of W2 Employees performing deliveries.

11. Number of contractors performing deliveries*

Number of 1099 Independent Contractors performing deliveries

12. Minimum age of delivery drivers*

13. What size of vehicles are used for delivery?*

Type of Vehicle	# of Vehicles

Please split out as appropriate. e.g. private auto, bicycle, box truck. Click the + sign to add each vehicle type

14. Does the insured use vehicle telematics? Are these in all vehicles and what data do they receive and how do they analyse it?*

15. Will drivers that are seen to have been speeding or committing any other driving offense be prevented from continuing to drive for the applicant?*

Yes
No

16. Details of MVR checks conducted on drivers and maximum number of offences permitted while still being able to drive for the company.*

16.1 Please upload a driver contract if availble

Drop files here or

Max. file size: 32 MB.

17. Are there background checks on drivers beyond MVR checks?*

Yes
No

17.1 What are these checks and who conducts them?*

18. Please provide a 10 year loss history FGU, uncapped.

Drop files here or

Max. file size: 32 MB.

19. Is there are rating system for drivers?*

Yes
No

19.1 Please explain how the rating system works?*

20. How are poorly performing drivers removed?*

21. What measures are being taking to reduce Distracted Driving?*

22. What procedures are in place to monitor vehicle recalls in relations to the vehicles being used on the platform?*

23. What extreme weather protocols are in place?*

CAPTCHA

Submit Your Application

Revenue, Deliveries & Miles