Transportation Insurance Application

Transportation Insurance Application

It only takes a few minutes to complete. We promise to never sell your information.

Company Name*
Owners Name(s)*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Physical Garaging Address same as the Mailing Address?*

YesNo
Physical Address: This location is your primary business address.

Street Address

Street Address Line 2

CityState / 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 *
Mile Radius *

General Underwriting Questions
1) Have you operated a trucking business under a different Authority or Name?*
3) Do you own or operate any equipment not scheduled on this application?*
4) Are Loaded Trailers ever left overnight, unattended or detached from power units?*
5) Do you ever haul oversize/overweight loads?*
6) Do you haul hazardous or waste materials?*
7) Do you do intermodal container hauling?*
8) Do you loan, lease or rent equipment to others?*
9) Team Driving?*
10) Do you have current insurance?*
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?*
12) Have you been cancelled or non renewed in past 3 years?*
Loss Runs File Upload

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Comments to any "Yes" responses

Coverage Limits
Auto Liability Limits*
Non-Trucking Liability (Bobtail)
Auto Liability Deductible*
Auto Physical Damage - Comp/Collision Deductible*
General Liability Limits*
Motor Truck Cargo Limit*
Motor Truck Cargo Deductible*
Refrigerated Breakdown (Reefer) Coverage?*

YesNo
Trailer Interchange Limits*
Vehicle Breakdown Coverage (Roadside Assistance Program)*
Occupational Accidental/Workers Compensation Coverage Limits*
Current Certificate of Insurance or Policy Declaration Pages File Upload

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Scheduled Vehicles
Number of Power Units?*
Vehicle #1 - Year Built*
Year
Make/Model*
GVW*
Type
VIN #*
Stated Amount Value*
Vehicle #2 - Year Built
Year
Make/Model
GVW
Type
VIN #
Stated Amount Value
Vehicle #3 - Year Built
Year
Make/Model
GVW
Type
VIN #
Stated Amount Value
Vehicle #4 - Year Built
Year
Make/Model
Type
GVW
VIN #
Stated Amount Value
Vehicle #5 - Year Built
Year
Make/Model
Type
GVW
VIN #
Stated Amount Value
Vehicle #6 - Year Bulit
Year
Make/Model
Type
GVW
VIN #
Stated Amount Value
Vehicle #7 - Year Bulit
Year
Make/Model
Type
GVW
VIN #
Stated Amount Value
Vehicle #8 - Year Built
Year
Make/Model
Type
VIN #
Stated Amount Value
Vehicle #9 - Year Built
Year
Make/Model
Type
GVW
Stated Amount Value
Vehicle #10 - Year Built
Year
Make/Model
Type
GVW
Stated Amount Value
Vehicle File Upload

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Scheduled Trailers
Number of Trailers?*
Trailer #1 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer #2 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer #3 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer # 4 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer # 5 - Year Built
Make/Model
VIN #
Stated Amount Value
Trailer # 6 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer # 7 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer # 8 - Year Built
Make/Model
Type
Stated Amount Value
VIN #
Trailer # 9 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer # 10 - Year Built
Make/Model
Type
VIN #
Stated Amount Value
Trailer File Upload

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Vehicle Questions
Do you perform routine maintenance on all vehicles?*
Vehicles are equipped with the following?*

Dash CamerasElectronic Log DeviceGPSAlarmsFire ExtinguishersNone of the Above
Are vehicles kept at secure location when not in use?*

Scheduled Drivers
Number of Drivers?
Are all drivers MVR's, references and background checked performed prior to hiring?*
Drivers Name - #1*

First NameLast Name
Date of Birth *
Drivers License and State Licensed in*
Date of Original CDL License (Month/Year)*
Commercial Driving Experience*
Drivers Name - #2

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #3

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #4

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #5

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #6

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #7

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #8

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #9

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Drivers Name - #10

First NameLast Name
Date of Birth
Drivers License and State Licensed in
Date of Original CDL License (Month/Year)
Commercial Driving Experience
Driver File Upload (Copies of Drivers Licenses or Motor Vehicle Reports)

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How did you hear about us?*
Name of Person Completing *
Effective Date of Policy*

MonthDayYear
Date
Should be Empty:

Transportation Insurance Application

General Underwriting Questions

Coverage Limits

Scheduled Vehicles

Scheduled Trailers

Vehicle Questions

Scheduled Drivers