• Request For An Endorsement

  Please take a moment to fill out the form.
• Name*
  First NameLast Name
• Organization Name*
• DOT Number
• Phone Number*
  Please enter a valid phone number.
• Email*
  example@example.com
• Preferred Method of Contact*
  PhoneEmailEither
• Effective Date of Endorsement?
   -Month -DayYear

  Date
• Select Endorsement*
  Please Select Adding/Removing A Driver Adding/Removing A Vehicle Adding/Removing Coverages Request Documents Cancellation Request Payment Request
• Back

  Next

• Drivers

• Are You Adding Or Removing This Driver?*
  AddingRemoving
• Driver 1*
  First NameLast Name
• Date Of Birth*
   -Month -DayYear

  Date
• Driver 1 License Number*
• Driver 1 State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
• Does Driver 1 Have A CDL?*
  YesNo
• Upload Driver 1 License
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Drivers?*
  YesNo
• Back

  Submit

  Next

• Drivers

• Are You Adding Or Removing This Driver?*
  AddingRemoving
• Driver 2*
  First NameLast Name
• Date Of Birth*
   -Month -DayYear

  Date
• Driver 2 License Number*
• Driver 2 State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
• Does Driver 2 Have A CDL?*
  YesNo
• Upload Driver 2 License
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Drivers?*
  YesNo
• Back

  Next

• Drivers

• Are You Adding Or Removing This Driver?*
  AddingRemoving
• Driver 3*
  First NameLast Name
• Date Of Birth*
   -Month -DayYear

  Date
• Driver 3 License Number*
• Driver 3 State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
• Does Driver 3 Have A CDL?*
  YesNo
• Upload Driver 3 License
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Drivers?*
  YesNo
• Back

  Submit

  Next

• Drivers

• Are You Adding Or Removing This Driver?*
  AddingRemoving
• Driver 4*
  First NameLast Name
• Date Of Birth*
   -Month -DayYear

  Date
• Driver 4 License Number*
• Driver 4 State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
• Does Driver 4 Have A CDL?*
  YesNo
• Upload Driver 4 License
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Drivers?*
  YesNo
• Back

  Submit

  Next

• Drivers

• Are You Adding Or Removing This Driver?*
  AddingRemoving
• Driver 5*
  First NameLast Name
• Date Of Birth*
   -Month -DayYear

  Date
• Driver 5 License Number*
• Driver 5 State*
  Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State
• Does Driver 5 Have A CDL?*
  YesNo
• Upload Driver 5 License
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Need To Add More Drivers?*
  YesNo
• Back

  Submit

  Next

• Vehicles

• Are You Adding Or Removing Vehicle 1?*
  AddingRemoving
• Vehicle 1 Year*
  Ex: 2022
• Vehicle 1 Make*
  Ex: Freightliner
• Vehicle 1 Model*
  Ex: Cascadia
• Vehicle 1 Vin*
  Ex: 1FUJGLDR19LAJ1817
• Would You Like Physical Damage For Vehicle 1?*
  YesNo(if yes, enter value)
• Vehicle 1 Comp & Collision Deductible
  $500$1000$2500$5000
• Additional Insured/Waiver Of Subrogation
• Loss Payee/Lienholder
• Upload Requirements for Loss Payee/Lienholder/Additional Insured
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Vehicles To Add?*
  YesNo
• Back

  Submit

  Next

• Vehicles

• Are You Adding Or Removing Vehicle 2?*
  AddingRemoving
• Vehicle 2 Year*
  Ex: 2022
• Vehicle 2 Make*
  Ex: Freightliner
• Vehicle 2 Model*
  Ex: Cascadia
• Vehicle 2 Vin*
  Ex: 1FUJGLDR19LAJ1817
• Would You Like Physical Damage For Vehicle 2?*
  YesNo(if yes, enter value)
• Vehicle 2 Comp & Collision Deductible
  $500$1000$2500$5000
• Additional Insured/Waiver Of Subrogation
• Loss Payee/Lienholder
• Upload Requirements for Loss Payee/Lienholder/Additional Insured
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Vehicles To Add?*
  YesNo
• Back

  Submit

  Next

• Vehicles

• Are You Adding Or Removing Vehicle 3?*
  AddingRemoving
• Vehicle 3 Year*
  Ex: 2022
• Vehicle 3 Make*
  Ex: Freightliner
• Vehicle 3 Model*
  Ex: Cascadia
• Vehicle 3 Vin*
  Ex: 1FUJGLDR19LAJ1817
• Would You Like Physical Damage For Vehicle 3?*
  YesNo(if yes, enter value)
• Vehicle 3 Comp & Collision Deductible
  $500$1000$2500$5000
• Additional Insured/Waiver Of Subrogation
• Loss Payee/Lienholder
• Upload Requirements for Loss Payee/Lienholder/Additional Insured
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Vehicles To Add?*
  YesNo
• Back

  Submit

  Next

• Vehicles

• Are You Adding Or Removing Vehicle 4?*
  AddingRemoving
• Vehicle 4 Year*
  Ex: 2022
• Vehicle 4 Make*
  Ex: Freightliner
• Vehicle 4 Model*
  Ex: Cascadia
• Vehicle 4 Vin*
  Ex: 1FUJGLDR19LAJ1817
• Would You Like Physical Damage For Vehicle 4?*
  YesNo(if yes, enter value)
• Vehicle 4 Comp & Collision Deductible
  $500$1000$2500$5000
• Additional Insured/Waiver Of Subrogation
• Loss Payee/Lienholder
• Upload Requirements for Loss Payee/Lienholder/Additional Insured
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Any Other Vehicles To Add?*
  YesNo
• Back

  Submit

  Next

• Vehicles

• Are You Adding Or Removing Vehicle 5?*
  AddingRemoving
• Vehicle 5 Year*
  Ex: 2022
• Vehicle 5 Make*
  Ex: Freightliner
• Vehicle 5 Model*
  Ex: Cascadia
• Vehicle 5 Vin*
  Ex: 1FUJGLDR19LAJ1817
• Vehicle 5 Would You Like Physical Damage For Vehicle 5?*
  YesNo(if yes, enter value)
• Vehicle 5 Comp & Collision Deductible
  $500$1000$2500$5000
• Additional Insured/Waiver Of Subrogation
• Loss Payee/Lienholder
• Upload Requirements for Loss Payee/Lienholder/Additional Insured
  Browse Files

  Drag and drop files here

  Choose a file

  Cancelof
• Need To Add More Vehicles?*
  YesNo
• Back

  Submit

  Next

• Request Documents

• Request Document(s) Below*
  Please Select Loss Run MCS 90 OS-32 Filings Policy Documents Declaration Page Cargo Exclusions
• Back

  Submit

  Next

• Cancellation Request

• State Reason(s) For Cancellation Request
• Back

  Submit

  Next

• Coverages

• Select Coverage*
  Please Select Not Adding Coverages Increasing/Decreasing Auto Liability Increasing/Removing Motor Truck Cargo Increasing/Removing Physical Damage Adding/Removing UIIA Coverages Adding/Removing General Liability Adding/Removing Trailer Interchange Adding/Removing Non-Owned Trailer
• Back

  Submit

  Next

• Auto Liability

• Increasing Or Decreasing Auto Liability?*
  IncreasingDecreasing
• Auto Liability Limits*
  Please Select $750,000 $1,000,000 $1,500,000 $2,000,000
• Back

  Submit

  Next

• Motor Truck Cargo

• Adding Or Removing Motor Truck Cargo*
  AddingRemoving
• Motor Truck Cargo Limits*
  Please Select $50,000 $100,000 $150,000 $200,000 $250,000 $300,000
• Back

  Submit

  Next

• Physical Damage

• Adding Or Removing Physical Damage*
  AddingRemoving
• Physical Damage Amount?
• Vehicle Year*
  Ex: 2022
• Vehicle Make*
  Ex: Freightliner
• Vehicle Model*
  Ex: Cascadia
• Vehicle Vin*
  Ex: 1FUJGLDR19LAJ1817
• Back

  Submit

  Next

• UIIA Coverages

• Adding Or Removing UIIA Coverages*
  AddingRemoving
• Back

  Submit

  Next

• General Liability

• Adding Or Removing General Liability*
  AddingRemoving
• General Liability Limits*
  Please Select $1,000,000 $2,000,000 $1,000,000/$2,000,000 Aggregate
• Back

  Submit

  Next

• Trailer Interchange

• Adding or Removing Trailer Interchange?*
  AddingRemoving
• Trailer Interchange Value *
• Back

  Submit

  Next

• Non-Owned Trailer Physical Damage

• Adding or Removing Non-Owned Trailer Physical Damage?*
  AddingRemoving
• Value of Trailer*
• Back

  Submit

  Next

• Payment Requests

• What Would You Like To Do?*
  Please Select Payment Extension Request Add/Remove EFT
• Back

  Submit

  Next

• For EFT

• Adding Or Removing EFT*
  AddingRemoving
• Name*
  First NameLast Name
• Bank Name*
• Name On Account*
• Account Number*
• Routing Number*
• Signature*
• Back

  Submit

  Next

• A Representative Will Contact You Regarding Your Request.

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  Next

• This Is The End Of The Form. If You Are Finished Please Click Submit.

  For requests not listed. Send an email to Service@prestigetrucking.com
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