Truck Insurance

Interested in Truck Insurance? Fill out the form below and one of our specialists will contact you.

General Information

Insured Name (Company Name)(Required)

Insured Address(Required)

Street Address City State ZIP Code

If the insured has multiple locations, list all others:

Yes

Add all addresses

Complete Garaging Address(Required)

Street Address City State ZIP Code

Insured Email(Required)

FEIN/SS #(Required)

Date of Authority(Required)

(When the business started)

Insured Phone(Required)

Effective Date

Liability Limits $(Required)

UM/UIM Limits $

PIP/Med Pay Limits $

Additional Insured:

Upload License for Owner

Drop files here or

Max. file size: 10 MB.

Upload Licenses for Employees

Drop files here or

Max. file size: 10 MB.

Upload Loss Runs

Drop files here or

Max. file size: 10 MB.

Upload MVR

Drop files here or

Max. file size: 10 MB.

Upload Business Formation & Tax ID

Drop files here or

Max. file size: 10 MB.

Vehicle Information

Also list all Trailer Information and Non-Owned Trailer Coverage Amount if Needed

Year

Make

Model

Type

VIN #

GVW

Radius

Stated Value $

Driver Information

Name

Type

DOB

Yrs Experience

DL Number

License State

Date Hired

Do you require GL coverage

Yes

Do you require Cargo Coverage?

Yes

Prior Experience

*Required for new ventures and if business hasn't been running for 5 years. Owner Experience only

Start Date

End Date

Employer's Name

Job Title

Job Duties/Details

Cargo Information

Type of Cargo

Avg Value Per Load $

Max Value Per Load $

% of Total Loads

What are the limits require for cargo?

Where is company getting loads from: (ex. Load board, Dispatcher, Broker, etc)(Required)

Applicants Questions

1. Who is the registered owner of the business?

if the registered owner is an entity, identify the partners in the case of a partnership, members in the case of a limited liability company and shareholders in the case of a corporation.

Date of Birth(Required)

2. Do you required filings?(Required)

Yes

DOT#(Required)

MC#

3. Does your company conduct any business or travels outside the state of your business state?

Yes

If so, identify all the states in which your company does business or travel to.

4. How many total miles did your company vehicles travel in the past 12 months?

How many total miles do you anticipate your company vehicles will travel in the next 12 months?

5. Does your company lease any vehicles greater than 30 days that is not specifically listed on vehicle schedule?

Yes

Number/Amount of Vehicles

Type of Vehicle

Lessor's name

6. How many loads does each company vehicle deliver, on average, per day?

7. Do your company vehicles haul double/triple trailers and/or oversized loads?

Yes

8. Do you sub-contract with or use sub-haulers or leased operators?

Yes

9. Do you lease or hire out your vehicles out to anyone else?

Yes

10. Are you required by any contract(s) to maintain Hired and Non-Owned Auto Coverage?

Yes

If so, identify each such contract

11. What's your company's annual payroll?

12. What is your company's Annual Gross Revenue?

13. How many years has your company been in business?

14. Are any of your company vehicles insured by another insurance carrier?

Yes

Auto Liability

Physical Damage

Cargo Coverage

15. Does your company have a safety program for its drivers?

Yes

If so, set forth how many hours of safety training each driver is required to attend per year.

16. Do you have plans to increase the number of vehicles owned by your company within the next year?

Yes

17. Do you have plans to increase the number of vehicles operated by your company within the next year?

Yes

18. Has the applicant ever done business under a different name?

Yes

List the company names

19. Has the applicant ever operated under a different DOT or MC #?

Yes

If so, list the DOC/MC#

20. With what company or customer is your largest contract? What is the annual gross revenue from this contract?

21. Are placards or Safety data sheets ever required for any vehicle your company operates?

Yes

22. Are all vehicle(s) exclusively garaged/parked in

23. Do you pick up or deliver to the 5 boroughs in New York?

Yes

if yes, please state % or number of loads per week

24. Do you haul intermodal containers?

Yes

25. Do you haul tanker-trailers?

Yes

26. Do you haul flatbed trailers?

Yes

If so, are they oversize/overweight or require a Moffet?

27. Are all vehicles used in your operation equipped with Electronic Log Devices or ELD?

Yes

ELD provider?

28. Applicant enrolled in drug/alcohol consortium CDL drivers to FMCSA drug and alcohol clearinghouse?

Yes

29. Are you interested in saving up to 15% by adding the camera program?

Yes

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

I hereby certify that the information contained in this application is true and agree that a misrepresentation of any of the facts by me will constitute reason for the company to void or cancel any policy issued on the basis of this application and will hold the company harmless for the action taken.

INSURED ACKNOWLEDGES THAT IF THEY CANCEL THE POLICY PER THEIR REQUEST OR DUE TO NON-PAYMENT OF PREMIUM THAT ANY REFUND/RETURN PREMIUM MAY BE LESS THAN PRO RATA.

Applicant Signature

3 + 7 =(Required)

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