Contact Submission Form

Company Name*

Who Referred You?*

Applicant Name*

First NameLast Name

Company Address*

Company Website

Phone Number*

E-mail*

example@example.com

Year Business Established*

Motor Carrier Coverages Needed:*

Proposed Effective Date*

Date

Motor Truck Cargo Limit

Trailer Interchange Limit

Is the Applicant a Motor Carrier?*

YesNo

DOT #

MC #

Is the Motor Carrier Subject to Any Filings?

YesNo

State and Federal Filings

Please upload current driver schedule with current MVR's.

Please upload current equipment schedule with values.

Gross Revenue*

List of Shippers / Shipper Names*

Please separate shipper names by a comma.

What type(s) of cargo do you arrange transportation for?*

Please list and separate cargo descriptions by a comma.

Do you ship refrigerated and/or perishable cargoes?

YesNo

Please upload IFTA Reports from last 4 Quarters.

Please upload current coverages (ex. Declaration page, Acord form, Policy). (Optional, 10MB Limit)

General Deductible $*

For all coverages requested, have you had any covered or non-covered losses in the past 5 years?

YesNo

Were all losses covered by the primary insurance?

YesNo

Please upload a document providing full details on all losses.

In the past 5 years, have you ever had insurance cancelled, declined, or the policy renewal refused?

YesNo

SIGNATURE

I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the Insurance Company.

WARRANTY:
The Applicant hereby applies to the Company for a policy of insurance as set forth in this application on the basis of statements contained here. Applicant agrees that such policy shall be null and void if such information is materially false or misleading so that the Company would have rejected the risk, prior to inception. Applicant understands that an inquiry may be made which will provide applicable information concerning character, general reputation, financial stability, and other pertinent financial data, personal characteristics, mode of living, or other background information the Company deems necessary in order to determine whether the Company will accept or reject applicant for coverage.

The undersigned authorizes the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof. Upon written request, additional information as to the nature and scope, if one is made, will be provided. The undersigned authorized officer of the Applicant declares that the statements set forth herein are true.

The undersigned authorized officer agrees that if the information supplied on this application changes between the date of this application and the effective date of insurance, he/she (undersigned) will, in order for the information to be accurate on the effective date of the insurance, immediately notify the Company of such changes, and the Company may withdraw or modify any outstanding quotations and/or authorizations or agreements to bind the insurance.

The Applicant understands this application is a request for quotation and no information provided herein shall be construed by either party as creating a binding contract for insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued, and it will be attached to and become part of the policy.

All written statements and materials furnished to the Company in conjunction with this application are hereby incorporated by reference into this application and made a part hereof.

Applicant's Printed Name

Applicant's Signature

Transportation Insurance RFQ

Exposure

Insurance Coverage and Limits

Loss Runs