Insurance Proposal Request - Primary Liability & Cargo

1

Are you an Individual or Company?

IndividualCompany

2

owner id

3

Is IC Individual

YesNo

4

Do you have your own Authority?* This field is required.

YesNo/Unsure

5

DeleteKeyText

6

DOT Number

7

Is this a new Authority?

YESNO

8

Do you have a state filing?

YESNO

9

Named Insured or Company Name

DBA

10

Address

Street Address

City

State

Zip Code

11

Phone NumberBest phone number to contact you.

12

Email* This field is required.

example@example.com

13

Owner's Full Name

14

Owner Date-of-Birth

Date

15

Owner's Social Security Number* This field is required.By providing this information, you agree to have credit-based scoring run and applied, which results in a "soft" credit inquiry on your credit history.

Enter either a full social security number, or at least the last 4 digits.

16

Federal ID Number(also called EIN number)

17

Requested Start Date of Policy(or your renewal date)

Date

18

What is the name of the Motor Carrier you are leased onto?* This field is required.

19

Do you know the DOT of the Motor Carrier you are leased onto?

YESNO

20

What is the DOT number of the Motor Carrier you are leased onto?

21

What is the address of the Motor Carrier you are leased onto?

22

How many years have you owned a truck?

23

Estimated Annual Revenue

24

Estimated Annual Mileage

25

What States do you drive in?For Example; Michigan, Ohio, Indiana, etc.

26

What major cities do you drive in?For example; Chicago, Detroit, New York, etc.

28

What is your average radius?

29

What percentage of your driving is within a radius of 1-75 miles?Estimating a percentage is ok

30

What percentage of your driving is within a radius of 76-150 miles?Estimating a percentage is ok

31

What percentage of your driving is within a radius of 151-300 miles?Estimating a percentage is ok

32

What percentage of your driving is within a radius of 301-500 miles?Estimating a percentage is ok

33

What percentage of your driving is within a radius of 500 or more miles?Estimating a percentage is ok

34

Do you have a current truck insurance policy? If so, with what company?

35

Are there any losses on the current truck insurance policy?

YESNO

36

How many drivers would you like to add to the policy?

37

Driver 1: Full Name

38

Driver 1: Date of Birth

Date

39

Driver 1: CDL StateUse the state's 2 letter abbreviation

40

Driver 1: Driver License Number

41

Driver 1: Years of CDL Driving

42

Driver 1: Date of Hire

Date

43

Driver 2: Full Name

44

Driver 2: Date of Birth

Date

45

Driver 2: CDL State

46

Driver 2: Driver License Number

47

Driver 2: Years of CDL Driving

48

Driver 2: Date of Hire

Date

49

Driver 3: Full Name

50

Driver 3: Date of Birth

Date

51

Driver 3: CDL State

52

Driver 3: Driver License Number

53

Driver 3: Years of CDL Driving

54

Driver 3: Date of Hire

Date

55

Driver 4: Full Name

56

Driver 4: Date of Birth

Date

57

Driver 4: CDL State

58

Driver 4: Driver License Number

59

Driver 4: Years of CDL Driving

60

Driver 4: Date of Hire

Date

61

Driver 5: Full Name

62

Driver 5: Date of Birth

Date

63

Driver 5: CDL State

64

Driver 5: Driver License Number

65

Driver 5: Years of CDL Driving

66

Driver 5: Date of Hire

Date

67

How many tractors would you like to add to the policy?

68

Tractor 1: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

69

Tractor 1: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

70

Tractor 1: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

71

Tractor 1: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

72

Tractor 1: Type

73

Tractor 2: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

74

Tractor 2: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

75

Tractor 2: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

76

Tractor 2: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

77

Tractor 2: Type

78

Tractor 3: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

79

Tractor 3: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

80

Tractor 3: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

81

Tractor 3: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

82

Tractor 3: Type

83

Tractor 4: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

84

Tractor 4: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

85

Tractor 4: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

86

Tractor 4: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

87

Tractor 4: Type

88

Tractor 5: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

89

Tractor 5: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

90

Tractor 5: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

91

Tractor 5: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

92

Tractor 5: Type

93

Do you have any Trailers?

YESNO

94

How many trailers would you like to add to the policy?

95

Trailer 1: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

96

Trailer 1: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

97

Trailer 1: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

98

Trailer 1: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

99

Trailer 1: Type

100

Trailer 2: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

101

Trailer 2: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

102

Trailer 2: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

103

Trailer 2: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

104

Trailer 2: Type

105

Trailer 3: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

106

Trailer 3: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

107

Trailer 3: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

108

Trailer 3: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

109

Trailer 3: Type

110

Trailer 4: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

111

Trailer 4: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

112

Trailer 4: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

113

Trailer 4: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

114

Trailer 4: Type

115

Trailer 5: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

116

Trailer 5: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

117

Trailer 5: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

118

Trailer 5: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

119

Trailer 5: Type

120

Communication Preferences

121

How should we Contact You?

Call Me

Email Me

Call or Email Me

122

Other Info

123

Todays Date

Date

124

Other information we should know?