Trucking Affiliate Partner Form

1
Insureds Business Name * This field is required.
2
Business Owners Name* This field is required.
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Initial
Last Name
Suffix
3
Business Owners DOB
Month
Day
Year
4
Insured's Phone NumberI agree to be contacted by Edge Insurance Agency LLC via call, email, and text. To opt-out, you can reply 'stop' at any time or click the unsubscribe link in the emails. Message and data rates may apply. https://www.edgeinsuranceagency.com/privacypolicy
Please enter a valid phone number.
5
Insured's E-mail* This field is required.
example@example.com
6
Insured's US DOT #* This field is required.
7
Insured's Number Of Vehicles* This field is required.
Select Insureds # of Vehicles Here
Select Insureds # of Vehicles Here
1
2
3
4
5
6
7
8
9
10 or more...
8
Equipment Type* This field is required.
Box Truxk
Dump Truck
Hot Shot
Semi-Car Hauler
Semi-Dry Van
Semi-Flatbed
Semi-Power Only
Semi-Reefer
Sprinter/ Cargo Van
9
Insured's Number Of Drivers* This field is required.
Select Insureds # of Drivers Here
1
2
3
4
5
6
7
8
9
10 or more...
10
Insured's Type Of Cargo* This field is required.
Types of Cargo
Types of Cargo
General Freight
Building Materials
Refrigerated
Agricultural
Dirt, Sand, and Gravel
Logging/ Wood Chips
Auto Hauler
Coal
Containers
Debris Removal
Escort Vehicles
Expediters
Fracking, Sand, or Water
Freight Forwarder
Garbage or Trash
Hazardous Materials/ Placards
Hot Shot Transport
Household Goods Mover
Livestock
Machinery and Heavy Equipment Hauler
Mobile Home Toter
Oilfield Materials
Scrap Metal/ Scrap Autos
Steel
Other For-Hire Trucking
11
Insured's Cargo Limit* This field is required.
Select Insureds Cargo Limit Here
Select Insureds Cargo Limit Here
$50,000
$100,000
$250,000
Other
12
Insured's Radius Of Operation* This field is required.
Select Insureds Radious of Operations Here
Select Insureds Radious of Operations Here
Local....... 0-50 Miles
Intermediate 51-200 Miles
Regional.... 200-500 Miles
Long Hual... 500+ Miles
13
Does the Insured Currently Have Insurance?* This field is required.
Yes
No
14
Liability Limit Needed* This field is required.
Select Insureds Liability Limit Here
Select Insureds Liability Limit Here
$300,000
$500,000
$750,000
$1,000,000
Other
15
Select Affiliate Partner Here* This field is required.
Other
Find Your Name Here
Wilson
Windon
Craig
Other
Should be Empty: