Commercial Trucking Insurance Please complete the form below. Insured Name (Company Name) * Insured Address * Address 1 Address 2 City State/Province Zip/Postal Code Country If the insured has multiple addresses , list all others Yes No Garaging Address (where you store equipment) Address 1 Address 2 City State/Province Zip/Postal Code Country Email * EIN/SS * Owner Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Additional Insured (Finance Company Info) Effective Date * MM DD YYYY How long has your company been in business? * Loss Payees/Lease? * Yes No Vehicle Information Year * Make * Model * GVW * Date of Purchase * MM DD YYYY Vehicle Type Box Truck Tractor Dump Truck Cargo Van Reefer Truck Hot Shot Tow Truck VIN # * Stated Value * $ Are you insuring more than one vehicle? * Yes No If yes, please provide all vehicle info. (VIN, value, make, etc.) Is this unit owned or a long term rental? * Owned Long Term Rental Identify other owned or long term rentals. Do you have plans to increase the number of vehicles in your fleet within the next year? Yes No Trailer Information Year Make Model GVW VIN # Stated Value $ Is this unit owned or a long term rental? * Owned Rental Add additional trailers. Include all info (VIN #'s, value, make, etc.) Driver Information Driver Name * First Name Last Name Title * Owner Owner Operator Employee Date of Birth * MM DD YYYY Years of Experience * List Experience (include company name & dates) * Does driver have a CDL? * Yes No Drivers License # * License State * Date Obtained * MM DD YYYY Date Hired * MM DD YYYY Add additional drivers, license #'s, state issuance, and DOB Coverage Questions Do you currently have a commercial auto policy? * Yes No Do you require cargo coverage? * Yes No Do you require GL coverage? * Yes No Description of Operations Business Type * Individual Partnership Corporation LLC Other What mile radius will you be traveling? * 100-300 miles 300-500 miles 500+ miles If tow truck, do you perform repos? Yes No Will there be residential deliveries (e.g. furniture/appliances) * Yes No Which cargo types do you transport? Select all that apply. * Dry Goods Refrigerated Intermodal Containers Auto Hauler Pharmecutical Electronics Does your company conduct business or travel beyond the state lines? * Yes No Do you haul hazardous materials? * Yes No Do you rent or lease your vehicles to others? * Yes No Do your company vehicles haul double/triple trailers and/or oversized loads? * Yes No Do you travel to any of the five boroughs of New York? * Yes No Has the applicant done business under a different name? * Yes No Do you have an ELD? * Yes No Type of Insurance Requesting Select Coverages Needed * Auto Liability General Liability Motor Truck Cargo Physical Damage (comp & collision) Roadside Assistance Workers' Compensation Desired Coverage Amounts Liability Limits * $750,000 $1,000,000 $1,500,000 Other UM/UIM $ PIP/Med Pay Limits $ General Liability Motor Truck Cargo * $100,000 $250,000 $500,000 Other Physical Damage (Value of Truck) * $ Desired Deductible ($1000, $2000) * $ Applicant Questions Do you require federal filings * Yes No DOT * MC Date of Authority * MM DD YYYY How did you hear about us? Facebook/Instagram Google Family/Friend Email Thank you for your submission. One of our agents will contact you shortly.
