Truck Insurance - Trucking with Excel

General Information

Insured Name (Company Name)(Required)

Insured Email(Required)

FEIN/SS #(Required)

Insured Phone(Required)

Liability Limits $(Required)

UM/UIM Limits $

PIP/Med Pay Limits $

Additional Insured:

Vehicle Information

Driver Information

Cargo Information

What are the limits require for cargo?

How are vehicle(s) secured when unoccupied?

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)

DOT#(Required)

MC#

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?

Number/Amount of Vehicles

Type of Vehicle

Lessor's name

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

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?

Auto Liability

Physical Damage

Cargo Coverage

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

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

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

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

ELD provider?

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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