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Business Owners Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Business Owner's Date of Birth
*
-
Month
-
Day
Year
Date
Business Owners Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Start Date?
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ASAP
Next Month
2+ Months
3+ Months
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Month
-
Day
Year
Date
Do you have a USDOT Number?
*
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Yes
No
Not Yet
N/A
Please enter your USDOT NUMBER:
What is the business entity type?
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Individual/Sole Propretor
LLC
Corp
Partnership
Other
Business Name
*
Years In Business
*
Please Select
New Business
1
2
3
4-10
11+
Current Insurance Carrier
Is the business address the same as the owners home address?
*
Yes
No
Please Enter The Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What type of trucks will you be running? Mark all that apply
*
Hotshot
Semi Truck
Box Truck
Dump Truck
Tow Truck
Cargo Van
Other
Type of Cargo Hauled
*
Radius Of Operations
*
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50 Miles
200 Miles
500 Miles
Unlimted Miles
Garaging Zip Code
Do you have an Electronic Logging Device (ELD)?
Please Select
Yes
No
Not Yet
Name your ELD Provider
How many trucks will you have?
*
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1
2
3
4
5
6
Fleet
Fleet Truck Schedule Upload
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Fleet Truck/Trailer Schedule Upload
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How many trailers will you have?
*
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0
1
2
3
4
5
6
Fleet
Vehicle 1: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 1: Enter VIN
Leave Blank If Unknown
Vehicle 1: Stated Value
How much is the vehicle worth today?
Vehicle 2: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 2: Enter VIN
Leave Blank If Unknown
Vehicle 2: Stated Value
How much is the vehicle worth today?
Vehicle 3: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 3: Enter VIN
Leave Blank If Unknown
Vehicle 3: Stated Value
How much is the vehicle worth today?
Vehicle 4: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 4: Enter VIN
Leave Blank If Unknown
Vehicle 4: Stated Value
How much is the vehicle worth today?
Vehicle 5: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 5: Enter VIN
Leave Blank If Unknown
Vehicle 5: Stated Value
How much is the vehicle worth today?
Vehicle 6: Enter Year, Make and Model
Example: 2020 Ford F-150
Vehicle 6: Enter VIN
Leave Blank If Unknown
Vehicle 6: Stated Value
How much is the vehicle worth today?
Trailer 1: Enter Year, Make and Model
Trailer 1: Enter Vin
Leave Blank If Unknown
Trailer 1: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
Trailer 2: Enter Year, Make and Model
Trailer 2: Enter Vin
Leave Blank If Unknown
Trailer 2: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
Trailer 3: Enter Year, Make and Model
Trailer 3: Enter Vin
Leave Blank If Unknown
Trailer 3: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
Trailer 4: Enter Year, Make and Model
Trailer 4: Enter Vin
Leave Blank If Unknown
Trailer 4: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
Trailer 5: Enter Year, Make and Model
Trailer 5: Enter Vin
Leave Blank If Unknown
Trailer 5: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
Trailer 6: Enter Year, Make and Model
Trailer 6: Enter Vin
Leave Blank If Unknown
Trailer 6: Stated Value
Type of Trailer:
Example: Flatbed, Dry Van, Gooseneck, Auto Hauler, Etc
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Is the business owner a driver?
*
Please Select
Yes
No
Owners Drivers License Number
License State
Does the Business Owner have a CDL?
Yes
No
What year was the CDL issued?
Fleet Drivers Info Schedule Upload
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Number Of Additional Drivers
*
Please Select
0
1
2
3
4
5
6
Fleet
Add Driver (1)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Add Driver (2)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Add Driver (3)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Add Driver (4)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Add Driver (5)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Add Driver (6)
First Name
Last Name
Date of Birth
License Number
License State
CDL
Yes
No
Year CDL Issued
Coverages Needed? Mark all that apply
Auto Liability
Cargo
General Liability
Physical Damage
Workers Comp
Trailer Interchange
Bobtail (Non-Trucking Liability)
Umbrella
Occupational Accident
Other
Comments For The Agent
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Truck, Trailer, Driver, IFTA'S Info
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