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Years in Business*

Number of power units*

Radius of operation*

Please select the coverages that you need for your business

 
Primary Liability - – I have my operating authority and MC Number, or applying for one
Bobtail Liability - Non-trucking liability. I am leased on to another motor carrier. Don’t need MC#
Physical Damage - collision and comprehensive coverage for my equipment
Cargo - coverage for the cargo that I am transporting
Occupational Accident - covers injuries that I sustain while operating my truck
Truckers General Liability - provides broader business liability protection for my company
Truckers Roadside Services - covers towing, labor, flat tire, vehicle winching/extricating and more

Your Company Name*

DOT (specify number or pending)*

Contact phone*

Email Address*

Physical Address (No PO Box)*

City*

State*

Zip code*

Owner's Birth Date*

Owner's Full Name*

 

List all drivers

Driver 1 Name (First, Last)*

License Number and State*

Driver's Birth Date*

Years of CDL

Driver 2 Name (First, Last)

License Number and State

Driver's Birth Date

Years of CDL

Driver 3 Name (First, Last)

License Number and State

Driver's Birth Date

Years of CDL

Driver 4 Name (First, Last)

License Number and State

Driver's Birth Date

Years of CDL

List all vehicles and trailers that you operate

Year*

Type*

Make*

Current Value*

Year

Type

Make

Current Value

Year

Type

Make

Current Value

Year

Type

Make

Current Value

Additional Questions

 

Do you currently have any insurance coverage for your equipment? *

Yes

No

If YES, Who is your insurance carrier (not agent or broker)?

Current policy expiration date

Have you had a trucking authority in the past? *

Yes

No

If YES, List prior name and DOT number

List type of commodities (cargo) transported

Any additional requests or comments