C5 - Non-Trucking Liability

C5 - Non-Trucking Liability

We have processed over 600 applicants and provide expedited proposals within 3 Business days (Depending Upon State), accurate every time, guaranteed. This is a FAST LANE, expedited service and requires an application fee, but puts you in the position to be on the road driving for C5.
Policy
Sender Name
Reply Email
example@example.com
Agency
Monday.com Title
Customer
First Name*
Last Name*
Full Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Mailing / Billing Address (This Is The Location Where You Garage The Vehicle)*

Street Address

Street Address Line 2

CityState

Zip Code
Driver's License #*
Driver's License State (Abbreviation)*
Your Company Name (If Applicable) - Please Include LLC or Inc. If Applicable
Target Start Date

MonthDayYear
Date
Has this driver had any accidents or violations in the past 5 years? *NOTE* THIS COULD AFFECT PREMIUM PRICING AT TIME OF POLICY ISSUANCE.*

NoYes
Approximate Date of Accident/Incident*

MonthDayYear
Date
Description of Incident/Accident*
Are you storing/parking the vehicle in a location different than the mailing address above?*

YesNo
Address of vehicle when storing/parking.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOT # (If Applicable), Leave Blank If Driving Under Someone Else's DOT Number.
FEIN # (If you are waiting on one, please type "Waiting")*
Do you own or lease/rent the vehicle?*

OwnLease
I am leasing/renting from:*

EnterpriseKingbee (You are required to purchase physical damage insurance from MM Insurance)Other
Vehicle Year (Vehicle Must Be 12 Years Or Newer To Qualify)*
Vehicle Make & Model*
Ex: Ford Transit
Vehicle VIN # (YOUR QUOTE WILL BE DELAYED UNTIL THE VIN IS PROVIDED FOR THE VEHICLE YOU OWN OR ARE RENTING)*
As of today, do you currently have coverage in force for this vehicle? If you do, a discount is applied of 10%*

YesNo
Please provide a picture of your current insurance card. REQUIRED.*

Cancelof
What carrier is the current coverage with?*
Ex: Progressive
Company you will be driving for.
In addition to Non-Trucking Liability, please select one of the following.*

I need Physical Damage CoverageI am getting Physical Damage Coverage through the truck rental companyI do not require Physical Damage CovergeShow Me A Video Explaining This In More Detail **DO NOT LEAVE THIS OPTION SELECTED WHEN SUBMITTING YOUR APPLICATION - AFTER YOU WATCH THE VIDEO PLEASE SELECT YOUR CORRECT OPTION ABOVE**
What deductible would you like? (Note: The higher the deductible, the lower the premium).

$1,000$2,000
What Is Physical Damage Coverage?
I would like uninsured/underinsured motorist coverage. (Electing this coverage does yield additional premium. This coverage is important but not required by trucking companies).

YesNoShow Me A Video Explaining This In More Detail **DO NOT LEAVE THIS OPTION SELECTED WHEN SUBMITTING YOUR APPLICATION - AFTER YOU WATCH THE VIDEO PLEASE SELECT YOUR CORRECT OPTION ABOVE**
Uninsured/Underinsured Motorist
Longest Distance Traveled (Away From My Home Address)*
Do You Need State Or Federal Filings (Please answer "Neither" if you are driving under another trucking company's authority):*

Neither (I am driving under someone else's authority)BothState OnlyFederal Only
What is your MC(Motor Carrier) Number or the MCS90 and Federal Filing*
In order for your Federal Filing to be accepted by the FMCSA your address on the insurance policy must exactly match the address on file with FMCSA. (Ex. Suite Number/Unit, Spacing etc.). I confirm that the address listed above PRECISELY matches the FMCSA address. PLEASE DOUBLE CHECK.*

YesNo
Please include the telematics discount of 5-10% on my proposal. I AM interested in enrolling in the app that monitors my speed, safe driving habits. (ie - Progressive's Telematics program is called SmartHaul).

YesNo
Non Trucking Liability coverage is not the same as full auto liability coverage. I will be driving under the authority of another company as a subcontractor. While I am driving under their authority (under load), I understand that their liability insurance is primary and responsible. If I am driving under my own authority, I need full auto liability coverage. Non Trucking liability coverage protects me (my vehicle) while I am driving not under load ONLY. Because the trucking company I drive for carries full auto liability while I am driving under load, I only need NTL coverage to cover the gap.*

I Acknowledge
**Error - Please Fix**

One of the questions above has "Show Me A Video Explaining This In More Detail" selected. Please select an appropriate answer otherwise your form cannot be submitted
** Quote Turnaround & Approved States ** - If your home address (included in the application above) is listed in the following states you are in our expedited program and can expect a quote within 3 Business days for your quote: AL, AZ, CO, CT, DE, FL, GA, KS, MD, MA, MI, NV, NJ, NC, OH, PA, SC, TX. If your address is not in these lists, we recommend that you contact a local agent.*

I Acknowledge That My Address Is In An Approved State Listed Above
I Understand & Acknowledge That There Is A Non-Refundable $45 Application / Processing Fee*

I Acknowledge

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Credit Card Details
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Credit Card Number	Security Code
Card Expiration

C5 - Non-Trucking Liability

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