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Transportation Insurance Application
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Company Name
*
Owners Name(s)
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Physical Garaging Address same as the Mailing Address?
*
Yes
No
Physical Address: This location is your primary business address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FEIN# or SS#
*
Please enter a valid FEIN to receive an accurate quote
DOT#
*
If no DOT # enter N/A
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How Long in Business
*
Years Experience in Industry
*
Commodities Hauled
*
Food and Beverages
Fresh produce (fruits and vegetables)
Packaged foods (canned goods, snacks, frozen meals)
Meat and poultry
Dairy products (milk, cheese, yogurt)
Beverages (soda, bottled water, alcohol)
Construction Materials
Lumber and wood products
Cement and concrete
Steel and metal products
Drywall and insulation
Roofing materials
Gravel, sand, and aggregate
Automotive Parts and Vehicles
Auto parts (engines, tires, batteries)
New and used cars
Motorcycles and recreational vehicles (RVs)
Hazmat Products
Flammable liquids (gasoline, diesel, chemicals)
Explosives and fireworks
Toxic and corrosive chemicals
Radioactive materials
Industrial chemicals
Paints and solvents
Fertilizers and pesticides
Cleaning agents
Trash and waste (landfills, recycling)
Recycling materials (plastic, aluminum, paper)
Consumer Goods
Electronics (TVs, computers, mobile phones)
Furniture and home goods
Clothing and apparel
Toys and games
Household appliances
Raw Materials and Bulk Products
Coal, oil, and natural gas
Grain (corn, wheat, rice, etc.)
Timber and pulp
Fertilizers and agricultural products
Mile Radius
*
Please Select
0-100
101-300
300-500
501+
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General Underwriting Questions
1) Have you operated a trucking business under a different Authority or Name?
*
Please Select
Yes
No
3) Do you own or operate any equipment not scheduled on this application?
*
Please Select
Yes
No
4) Are Loaded Trailers ever left overnight, unattended or detached from power units?
*
Please Select
Yes
No
5) Do you ever haul oversize/overweight loads?
*
Please Select
Yes
No
6) Do you haul hazardous or waste materials?
*
Please Select
Yes
No
7) Do you do intermodal container hauling?
*
Please Select
Yes
No
8) Do you loan, lease or rent equipment to others?
*
Please Select
Yes
No
9) Team Driving?
*
Please Select
Yes
No
10) Do you have current insurance?
*
Please Select
Yes
No
If So, What is the name and policy # of the current insurance company?
If So, Current policy premium?
11) Have you had any losses or claims in last 3 years?
*
Please Select
Yes
No
No Prior Coverage
12) Have you been cancelled or non renewed in past 3 years?
*
Please Select
Yes
No
No Prior Coverage
Loss Runs File Upload
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Coverage Limits
Auto Liability Limits
*
Please Select
1,500,000
1,000,000
750,000
500,000
300,000
100,000
Non-Trucking Liability (Bobtail)
Please Select
Yes
No
Auto Liability Deductible
*
Please Select
0
1,000
2,500
5,000
Auto Physical Damage - Comp/Collision Deductible
*
Please Select
N/A
1,000
2,500
5,000
General Liability Limits
*
Please Select
N/A
1,000,000/2,000,000 - Occ/Agg
500,000/1,000,000 - Occ/Agg
300,000/600,000 - Occ/Agg
100,000/200,000 - Occurrence/Aggregate
Motor Truck Cargo Limit
*
Please Select
N/A
25,000
50,000
100,000
150,000
200,000
250,000
350,000
500,000
1,000,000
Motor Truck Cargo Deductible
*
Please Select
N/A
1,000
2,500
5,000
Refrigerated Breakdown (Reefer) Coverage?
*
Yes
No
Trailer Interchange Limits
*
Please Select
N/A
25,000
30,000
35,000
40,000
50,000
60,000
70,000
75,000
80,000
85,000
90,000
100,000
Vehicle Breakdown Coverage (Roadside Assistance Program)
*
Please Select
Yes
No
Occupational Accidental/Workers Compensation Coverage Limits
*
Please Select
N/A
100,000/500,000
500,000/500,000
1,000,000/1,000,000
Current Certificate of Insurance or Policy Declaration Pages File Upload
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Scheduled Vehicles
Number of Power Units?
*
Please Select
1
2
3
4
5 or more
Vehicle #1 - Year Built
*
Year
Make/Model
*
GVW
*
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
VIN #
*
Stated Amount Value
*
Vehicle #2 - Year Built
Year
Make/Model
GVW
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
VIN #
Stated Amount Value
Vehicle #3 - Year Built
Year
Make/Model
GVW
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
VIN #
Stated Amount Value
Vehicle #4 - Year Built
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
VIN #
Stated Amount Value
Vehicle #5 - Year Built
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
VIN #
Stated Amount Value
Vehicle #6 - Year Bulit
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
VIN #
Stated Amount Value
Vehicle #7 - Year Bulit
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
VIN #
Stated Amount Value
Vehicle #8 - Year Built
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
VIN #
Stated Amount Value
Vehicle #9 - Year Built
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
Stated Amount Value
Vehicle #10 - Year Built
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
Mini Van
Tow Truck
Rollback Wrecker
Limo
Taxi
Bus
SUV
GVW
Stated Amount Value
Vehicle File Upload
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Scheduled Trailers
Number of Trailers?
*
Please Select
N/A
1
2
3
4
5 or more
Trailer #1 - Year Built
Make/Model
Type
Please Select
Car Trailer
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer #2 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Hopper
VIN #
Stated Amount Value
Trailer #3 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Hopper Bottom
Tanker
VIN #
Stated Amount Value
Trailer # 4 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer # 5 - Year Built
Make/Model
VIN #
Stated Amount Value
Trailer # 6 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer # 7 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer # 8 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
Stated Amount Value
VIN #
Trailer # 9 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer # 10 - Year Built
Make/Model
Type
Please Select
Dry Van
Step Deck
Flatbed
Dump
Refrigerated (Reefer)
Gooseneck
Tanker
Hopper Bottom
VIN #
Stated Amount Value
Trailer File Upload
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Vehicle Questions
Do you perform routine maintenance on all vehicles?
*
Please Select
Yes
No
Vehicles are equipped with the following?
*
Dash Cameras
Electronic Log Device
GPS
Alarms
Fire Extinguishers
None of the Above
Are vehicles kept at secure location when not in use?
*
Please Select
Yes
No
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Scheduled Drivers
Number of Drivers?
Please Select
1
2
3
4
5 or more
Are all drivers MVR's, references and background checked performed prior to hiring?
*
Please Select
Yes
No
Drivers Name - #1
*
First Name
Last Name
Date of Birth
*
Drivers License and State Licensed in
*
Date of Original CDL License (Month/Year)
*
Commercial Driving Experience
*
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #2
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #3
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #4
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #5
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #6
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #7
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #8
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #9
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Drivers Name - #10
First Name
Last Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Please Select
0-5 Months
6-12 Months
1-2 Years
3-5 Years
5+ Years
Driver File Upload (Copies of Drivers Licenses or Motor Vehicle Reports)
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How did you hear about us?
*
Please Select
Referral/Friend
Google
SMS
Phone Call
Text Message
Email
Postcard
Name of Person Completing
*
Effective Date of Policy
*
-
Month
-
Day
Year
Date
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