Insurance Proposal Request - Primary Liability & Cargo

1

Are you an Individual or Company?

IndividualCompany

2

Is IC Individual

YesNo

3

Do you have your own Authority?* This field is required.

YesNo/Unsure

4

DOT Number

5

Is this a new Authority?

YESNO

6

Do you have a state filing?

YESNO

7

Named Insured or Company Name

DBA

8

Address

Street Address

City

State

Zip Code

9

Phone NumberBest phone number to contact you.

10

Email* This field is required.

example@example.com

11

Owner's Full Name

12

Owner Date-of-Birth

Date

13

Owner's Social Security Number* This field is required.By providing this information, you agree to have credit-based scoring run and applied, which results in a "soft" credit inquiry on your credit history.

Enter either a full social security number, or at least the last 4 digits.

14

Federal ID Number(also called EIN number)

15

Requested Start Date of Policy* This field is required.(or your renewal date)

Date

16

What is the name of the Motor Carrier you are leased onto?* This field is required.

17

Do you know the DOT of the Motor Carrier you are leased onto?

YESNO

18

What is the DOT number of the Motor Carrier you are leased onto?

19

What is the address of the Motor Carrier you are leased onto?

20

How many years have you owned a truck?

21

Estimated Annual Revenue

22

Estimated Annual Mileage

23

What States do you drive in?For Example; Michigan, Ohio, Indiana, etc.

24

What major cities do you drive in?For example; Chicago, Detroit, New York, etc.

26

What is your average radius?

27

What percentage of your driving is within a radius of 1-75 miles?Estimating a percentage is ok

28

What percentage of your driving is within a radius of 76-150 miles?Estimating a percentage is ok

29

What percentage of your driving is within a radius of 151-300 miles?Estimating a percentage is ok

30

What percentage of your driving is within a radius of 301-500 miles?Estimating a percentage is ok

31

What percentage of your driving is within a radius of 500 or more miles?Estimating a percentage is ok

32

Do you have a current truck insurance policy? If so, with what company?

33

Are there any losses on the current truck insurance policy?

YESNO

34

How many drivers would you like to add to the policy?

35

Driver 1: Full Name

36

Driver 1: Date of Birth

Date

37

Driver 1: CDL StateUse the state's 2 letter abbreviation

38

Driver 1: Driver License Number

39

Driver 1: Years of CDL Driving

40

Driver 1: Date of Hire

Date

41

Driver 2: Full Name

42

Driver 2: Date of Birth

Date

43

Driver 2: CDL State

44

Driver 2: Driver License Number

45

Driver 2: Years of CDL Driving

46

Driver 2: Date of Hire

Date

47

Driver 3: Full Name

48

Driver 3: Date of Birth

Date

49

Driver 3: CDL State

50

Driver 3: Driver License Number

51

Driver 3: Years of CDL Driving

52

Driver 3: Date of Hire

Date

53

Driver 4: Full Name

54

Driver 4: Date of Birth

Date

55

Driver 4: CDL State

56

Driver 4: Driver License Number

57

Driver 4: Years of CDL Driving

58

Driver 4: Date of Hire

Date

59

Driver 5: Full Name

60

Driver 5: Date of Birth

Date

61

Driver 5: CDL State

62

Driver 5: Driver License Number

63

Driver 5: Years of CDL Driving

64

Driver 5: Date of Hire

Date

65

How many tractors would you like to add to the policy?

66

Tractor 1: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

67

Tractor 1: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

68

Tractor 1: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

69

Tractor 1: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

70

Tractor 1: Type

71

Tractor 2: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

72

Tractor 2: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

73

Tractor 2: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

74

Tractor 2: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

75

Tractor 2: Type

76

Tractor 3: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

77

Tractor 3: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

78

Tractor 3: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

79

Tractor 3: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

80

Tractor 3: Type

81

Tractor 4: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

82

Tractor 4: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

83

Tractor 4: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

84

Tractor 4: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

85

Tractor 4: Type

86

Tractor 5: YearIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

87

Tractor 5: MakeIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

88

Tractor 5: VINIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

89

Tractor 5: ValueIf you just purchased this tractor and you don't know the specific details, enter your best guess here.

90

Tractor 5: Type

91

Do you have any Trailers?

YESNO

92

How many trailers would you like to add to the policy?

93

Trailer 1: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

94

Trailer 1: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

95

Trailer 1: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

96

Trailer 1: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

97

Trailer 1: Type

98

Trailer 2: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

99

Trailer 2: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

100

Trailer 2: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

101

Trailer 2: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

102

Trailer 2: Type

103

Trailer 3: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

104

Trailer 3: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

105

Trailer 3: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

106

Trailer 3: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

107

Trailer 3: Type

108

Trailer 4: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

109

Trailer 4: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

110

Trailer 4: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

111

Trailer 4: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

112

Trailer 4: Type

113

Trailer 5: YearIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

114

Trailer 5: MakeIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

115

Trailer 5: VINIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

116

Trailer 5: ValueIf you just purchased this trailer and you don't know the specific details, enter your best guess here.

117

Trailer 5: Type

118

Communication Preferences

119

How should we Contact You?By clicking the checkbox labelled "Call/Text me" you agree to receive SMS messaging.

Call/Text Me

Email Me

Call/Text or Email Me

120

Other Info

121

Todays Date

Date

122

Other information we should know?