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COMMERCIAL AUTO APPLICATION
STATE
*
State you need insurance for
How did you hear about us:
*
Please Select
Google
Instagram
Facebook
Linked
Yelp
Referral
Walk-in
Website
Tivly
Partnership program
Street Sign
COMPANY INFORMATION
COMPANY NAME
COMPANY EMAIL
example@example.com
EIN
What year did you open the company?
Street Address:
City
State (Abbreviate)
Zipcode
Company EIN Letter
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Company formation certificate
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Loss runs
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Business type:
Please Select
LLC
CORP
INC
PARTNERSHIP
INDIVIDUAL
DBA
OTHER
How many years has this business been operating?
*
Have you had or have any other businesses doing the same type of operation?
*
if not applycable just type: N/A
Any change in ownership/management planned during the policy term?
If yes, please explain
Any change in ownership/management over last 3 years?
If yes, please explain
Federal Filings are required?
*
Yes
No
Will apply within 60 days
DO YOU HAVE A DOT IF SO PLEASE ADD
Are you going to operate:
*
Intrastate
Interstate
Both
N/A
WHAT TYPE OF SERVICE YOU PROVIDE
*
If General Freight , please list what type of merchandise
PLEASE LIST THE STATES YOUR ARE OPERATION OR WILL OPERATE
Do you currently have insurance?
*
Yes
No
Expired
No renewal was offered
Other
Does the customer currently have personal or commercial auto insurance?
*
Answer yes or no
Does your company have previous General Liability Insurance? (If so what is the expiration date)
Answer yes or no
IF YES, PLEASE CONFIRM:
INSURANCE COMPANY NAME
POLICY NUMBER
EXPIRATION DATE
/
Month
/
Day
Year
Date
CURRENT PREMIUM
Is this the price you are currently paying or did it go up for the renewal?
How long has the customer been with their current auto insurance company?
Whay codily injury limits does the customer currently have on their vehicle insurance?
Please Select
State Minimum
15/10
25/50
50/100
100/300
250/500
1M
1.5 M
OTHER
Select one if applicable
OWNER INFORMATION
OWNER FIRST NAME
OWNER LAST NAME
OWNER DOB
Are you married , single, separated
*
Owner social security # :
(This is optional)
PHONE #
EMAIL
example@example.com
ADDRESS
If the owner address is the same as the company address , type “same”
DRIVER INFORMATION
(Please confirm if the driver is also the owner)
Configurable list
*
Driver License
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Please upload all drivers license
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Motor Vehicle report
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If available
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VEHICLE INFORMATION
Vehicle List:
*
Do you have any trailer to insure?
Do you plan to increase the number of units?
*
If yes, for how many?
Are all vehicles owned, registered, leased, rented, and used in business scheduled in the application?
*
Brokerage or Freight Forwarding Authority or plan to obtain it during policy term?
*
Do you haul or will you haul hazmant during the term of the policy?
*
Do you have Video/Dash Cam?
*
If yes, how many?
If you need to add any additional insured or Waiver of Subrogation, please add here:
*
If not applicable type: N/A
Vehicle title or Registration
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We need the photo to verify the ownership and VIN# (Add all titles and registrations )
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Have you had any Claims in the last 5 years?
Do you use ELD (ELECTRONIC BOOK)?
*
If so please include the provider name(If not type N/A)
What is the farthest one-way distance (in miles) this vehicle travels for work?
Please Select
0-25
26-50
51-100
101-200
201-300
301-500
More than 500
Loss runs
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If you have previous insurance, please upload the loss runs as the company is going to ask for it.
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What type of Merchandise are you transporting?
Please Select
General Freight
Household Goods
Metal: sheets, coils, rolls
Motor Vehicles
Drive/Town away
Logs, Poles, Beams, Lumber
Building Materials
Machinery, Large Objects
Fresh Produce
Liquids/Gases
Intermodal Cont.
Passangers
Oilfield Equipment
Livestock
Grain, Feed, Hay
Coal/Coke
Meat
Garbage/Refuse
US Mail
Chimecals
Commodities Dry Bulk
Refrigerated Food
Beverages
Paper Produts
Utilities
Agricultural/ Farm Supplies
Construction
Water Well
Construction materials
Vehicles
Food
Farm
Vehicle(s) Garaging Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
COVERAGES
Please specify what type of policies are you looking for and amount of coverage.
Coverage Type:
*
Auto Liability
Cargo
Interchange
General Liability
Workers Compensation
AUTO LIABILITY:
Coverage Amount
$350,000
$500,000
$750,000
$1,000,000
$1,500,000
$2,000,000
Other
CARGO
Coverage Amount:
$75,000
$100,000
$150,000
$200,000
$250,000
$300,000
Other
GENERAL LIABILITY
Coverage Amount:
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$2,000,000
$5,000,000
Other
NON-TRUCKING
Coverage Amount:
$300,000
$500,000
$1,000,000
$2,000,000
PHYSICAL DAMAGE
Coverage Amount:
$250
$500
$750
$1,000
$2,000
$2,500
INTERCHANGE
Coverage amount
$50,000
$100,000
$150,000
$200,000
Other
UIIA
Coverage Amount:
$1,000,000
$2,000,000
Other
If the customer has a USDOT, Please add the FMCSA Snapshot and screenshot
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Add the Licensing and Insurance Screenshot
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This is were we can see the mc # and current insurance status
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FMCSA Insurance History
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