Applicant Name: (Contact name or owner)

E-Mail Address: 

Phone Number:

Cell Phone Number:

D/B/A Name: (Doing Business As name)

GARAGE ADDRESS (Where you park your trucks)

Street:

City:   

State: AlabamaArkansasFloridaGeorgiaIllinoisKentuckyLouisianaMichiganMissouriNorth CarolinaOhioOklahomaPennsylvaniaSouth CarolinaTennesseeVirginiaWisconsin

Zip Code:

COVERAGE NEEDED

Primary Coverage

        Liability        Physical Damage        Cargo

Non-Trucking (Bobtail) and Physical Damage

LIABILITY LIMITS

Amount: - $ Amount -$1,000,000$750,000$500,000     Other:

ICC/FHWA FILINGS

MC Number:      DOT Number:      GA Number:

TRAVEL INFORMATION

Radius: - Miles Travled From Home -Unlimited Miles600 Miles500 Miles300 Miles50 - 100 Miles (Furthest destination traveled)

States Traveled:

Cities Traveled:

CARGO LIMITS

Amount: - $ Amount -$100,000$50,000     Other: (Most shippers will require a $100,000 limit)

COMMODITIES

       Commodities                                                   %                   Value of Avg. Load                     Max value of Load

#1:

#2:

#3:

#4:

COMPANY HISTORY

Years In Business:      Current Policy Expiration Date:

Prior three year insurance carrier history.  If you did not have insurance in your name, please indicate the companies that you were leased on, or companies for which you were a driver.

             Dates                                    Insurance Company                                   Claims/Losses                                               Policy Amount

Year 1:

Year 2:

Year 3:

VEHICLE SCHEDULE

       Year                      Make/Model                                         GVW                                    Value                                   Deductible

#1:

#2:

#4:

#5:

#6:

#7:

#8:

#9:

DRIVER SCHEDULE

       Driver name (from CDL)                        DOB                    Yrs w/CDL            Date of hire                        # of Violations

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

Report the prior three year history for each driver.  When reporting violations, you should be specific as possible about the each violation. For example:  If for speeding:  14 miles over the limit.

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