AGENCY INFORMATION
AGENCY NAME
AGENCY CODE
City
State
CONTACT NAME
Phone
*
FAX
Email
*
INSURED INFORMATION
INSURED NAME
GARAGING ADDRESS
PHYSICAL ADDRESS
CITY
STATE
ZIP
DESIRED EFFECTIVE DATE
# YEARS PRIMARY LIABILITY COVERAGE UNDER ABOVE NAME
IF NON-TRUCKING LIABILITY, NAME OF COMPANY LEASED TO
1. .US DOT #
*
2. IS THERE BROKER AUTHORITY UNDER THIS FMCSA #?
YES
NO
3. COMMODITIES HAULED
4. MAJOR CITIES
5. STATES ENTERED
6. HAS RISK BEEN CANCELLED OR NON-RENEWED IN LAST 3 YEARS?
YES
NO
7. IS RISK COVERED BY WORKERS' COMPENSATION?
YES
NO
8. HOW MANY YEARS HAS INSURED OWNED COMMERCIAL EQUIPMENT
9. FILINGS NEEDED?
YES
NO
10. OWNER'S NAME
OWNER'S SSN
11. DO YOU PULL
DOUBLES
TRIPLES
BOTH
NEITHER
12. DO YOU ALLOW NON-EMPLOYEE PASSENGERS?
YES
NO
_
NAME
DATE OF BIRTH
LICENSE NUMBER
STATE
HIRED
# YEARS COMM'L DRIVING EXP.
LAST 3 YEARS # OF MOV VIOLATIONS
LAST 3 YEARS - # OF ACCIDENTS
VEHICLE INFORMATION
YEAR
MAKE
TRAILER TYPE
GVW
PRESENT VALUE
VIN #
RADIUS (MILES)
PRIOR CARRIER
POLICY DATES
COMPANY NAME OR PREVIOURS LESSEE NAME
POLICY NUMBER
PREMIUM AMOUNT
# OF CLAIMS
TOTAL PAID & RESERVED
COVERAGE & LIMITS
LIABILITY (SELECT ONE)
PRIMARY LIABILITY
NON-TRUCKING LIABILITY
AUTO LIABILITY LIMIT
UNINSURED MOTORIST LIMIT
UNDERINSURED MOTORIST LIMIT
MEDICAL PAYMENTS
HIRED AUTO
LIAB
PHYS DMG
CARGO
NON-OWNED AUTO(S)
# OF EMPLOYEES
TRAILER INTERCHANGE (UIIA AGREEMENT REQUIRED)
PHYSICAL DAMAGE
SPECIFIED CAUSES OF LOSS & COLLISION
COMPREHENSIVE & COLLISION
DEDUCTIBLE
COLLISION
OTHER THAN COLLISION
CARGO
COMMODITY TRANSPORTED
% OF TOTAL REVENUE
VALUE PER TRUCK LOAD (MAX)
VALUE PER TRUCK LOAD (AVE)
CARGO LIMIT
CARGO DEDUCTIBLE(S)
REEFER DEDUCTIBLE(S)
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