(1) An application for self-insurance shall be in writing and duly verified by the motor carrier making same.

(2) The application shall set forth a detailed statement of the financial assets and liabilities of the applicant and contain an express agreement on the part of the applicant motor carrier to the effect that if self-insurance is permitted, the motor carrier will promptly notify the Commission of any material change thereafter occurring in the motor carrier's financial status.

(3) The privilege of self-insurance may be withdrawn at any time by the Commission. The failure of a motor carrier to promptly notify the Commission of any material change in said motor carrier's financial status or failure to correctly exhibit to the Commission the motor carrier's financial status, either in an original application for self-insurance or in any subsequent report, shall be sufficient cause for revocation of the motor carrier's certificate of public convenience and necessity.

 

(Form P. S. C. "A" - Self-Insurance)

APPLICATION FOR SELF-INSURANCE

 

To the Department of Public Service Regulation

     of the State of Montana,

     Motor Carrier Division,

     Helena, Montana.

 

     The undersigned, ________________________________________ 

(official title of motor carrier applicant) hereby makes application to the Department of Public Service Regulation for self-insurance pursuant to Section 69-12-402, MCA, and in this behalf represents and shows unto the Commission as follows:

 

 

That the following is a full, true and correct statement of assets and liabilities of the applicant, to-wit:

 

               ASSETS                                                                                  LIABILITIES

(List real estate, household                                                         (List indebtedness secured

furnishing, automobiles,                                                               by mortgage, conditional

stocks and/or bonds and money                                                 bill of sale, lien, etc.,

in bank separately.)                                                                      separate from unsecured

                                                                                                        debts.)

_____________________________                                       __________________________

 

_____________________________                                       __________________________

 

_____________________________                                       __________________________

 

_____________________________                                       __________________________

 

_____________________________                                       Total indebt. $_______________

 ____

Total value as'ts. $_________                                                     Net worth $_________________

 

The undersigned motor carrier further promises and agrees that in the event self-insurance is permitted said motor carrier will promptly notify the Commission of any material change in the financial status of said motor carrier.

 

                      Dated at ____________________, Montana, this ________________, 19___

 

                                                                                                        __________________________

                                                                                                        (official title of motor carrier)

 

                                                                                                        By_________________________

                                                                                                        (title of person signing, i.e.,

                                                                                                        whether owner, manager,

                                                                                                        president or co-partner)

 

State of Montana                                                                          )

County of                                                                                       )

 

______________________________________________being first duly sworn upon oath

deposes and says:                 that he is_________________________________________

(state official capacity) of the________________________________________________

(official title of motor carrier) and makes this verification for and upon behalf of said motor carrier;

that he has read the above and foregoing application for self-insurance and knows the contents

thereof and that the matters and things therein stated are true of his own knowledge.

                                                                                       ________________________________

     Subscribed and sworn to before me this __________  day of _________________, 19___.

                                                                                      Notary public for the State of Montana

                                                                                      Residing at____________________________

                                                                                      My commission expires__________________

(Notarial Seal)