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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 Garaging Address where vehicles are normally kept when not in use.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FEIN# or SS#
*
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 Trucking Industry
*
Commodities Hauled
*
What is the MAX Value of the Commodities Hauled?
*
Normal Radius of Operation
*
Please Select
0-100
101-300
301-500
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
2) Do you operate as a Freight Forwarder, Freight Broker or arrange loads for others under the same MC/DOT Numbers as the trucking authority?
*
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
1,000,000
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
*
Vehicle Type
*
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
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
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
VIN #
Stated Amount Value
Vehicle #4 - Year Bulit
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
GVW
VIN #
Stated Amount Value
Vehicle #5 - Year Bulit
Year
Make/Model
Type
Please Select
Tractor
Dump Truck
Box Truck
Straight Truck
Pickup
Cargo Van
GVW
VIN #
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
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
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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