NEW VENTURE FORM
OWNER INFORMATION
1. Owner Name (First, Middle, Last):
2. Is the owner also a driver?
Yes
No
If “No,” Please Explain
3. Has the owner operated under a different business name before?
Yes
No
If “Yes,” Previous Business Name:
MC Number:
4.How many years of experience does the owner have in managing a trucking business?
5. Does the owner plan to expand their fleet or hire more drivers during the policy term?
Yes
No
If “Yes,” how many additional units or drivers are expected?
DRIVER INFORMATION
1. Driver Name
2.How long has the driver been operating commercial vehicles like tractor-trailers?
DRIVER’S EXPERIENCE - PAST 3 YEARS
Rows
Company Name
Contact Details
Dates of Employment From
Dates of Employment To
MC Number of the Previous Company
Position Held with the Company
1
2
3
I hereby certify that the above information is true and correct to the best of my knowledge
.
Print Agent's Name
Title
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(Signature of Agent)
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