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GENERAL INFO
Insured *
Business Owner *
Current Policy Expiration Date
Initial Policy or Expired¾
Garaging City/State/ZIP *
, (Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
CONTACT
Name *
Office Phone #
Office Fax
Cell Phone
E-Mail *
COMMODITIES Enter percentage of each Commodity hauled. Must total 100% - Total: 0%
Appliances
Automobile Parts
Automobiles
Batteries
Beer & Wine
Boats, Snowmobiles, etc.
Books/Periodicals
Building Materials (NOC)
Cameras & Photographic Equipment
Candy
Canned or Dry Goods
Carpets/Rugs (not Oriental)
Clothing
Coffee/Tea/Spices
Cosmetics
Cotton (baled 72 hours)
Dairy Products
Drugs (non-Prescription)
Dry Freight (undescribed)
Eggs
Electronic Parts
Electronics (not computers)
Fertilizer (dry)
Fish/Seafood (not shellfish)
Flyers/Leaflets
Fuel Oil/LPG/Gasoline
Furniture (New only)
General Freight (max 15%)
Glass/Glassware
Grains/Feed
Groceries/Produce
Hardware
Hay/Straw
Iron/Steel (structural)
Leather Goods
Liquor/Alcohol
Livestock
Lumber
Machinery (Heavy)
Machinery (Light)
Meat (Frozen/Boxed)
Milk
Ore
Paint/Varnish
Paper Products
Paper (rolled)
Pharmaceuticals
Pipe
Poultry (Fresh or Frozen)
Raw Rubber
Recreational Vehicles
Rubber Products
Sand/Gravel
Shellfish
Textiles (not Silk)
Tires & Tubes
Tobacco (raw)
Tools
Toys & Sporting Goods
Wires
Other - Specify
OPERATIONS
Radius (Select) 0 - 50 mi 51 - 200 mi 201 - 500 mi 501 - 1000 mi over 1000 mi
Do you have Federal Highway Authority?
Yes No
Do you use Owner Operators?
Do you permanently lease to others?
Do you trip lease to other ICC Carriers?
List all major cities operated into or through (separate by comma)
PRIOR INSURANCE HISTORYComplete for the last 3 years
New Venture, No Truck Insurance History
#
Insurance Company Name
Policy From
Policy Thru
1
2
3
LOSS INFORMATION Note: Carrier may require 3 years hard copy loss runs. Loss History Itemized Below No Loss History Will Fax Loss History to (770) 717-9511 ¾
Date of Loss
Description
Amount of Loss
4
DRIVER INFORMATION (Complete for ALL drivers)
Name
Date of Birth
Driver Licence
State of Issue
Years Exp.
Original CDL Date
(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ACCIDENTS/VIOLATIONS (Complete for ALL drivers)
Dr. #
Accidents/Violations (within 3 years)
Date
(Select) None, Clean Record Accident - At Fault Accident - NotAt Fault Careless Driving Drag Racing Driving under the Influence of Alcohol Driving under the Influence of Drugs Driving while License is Suspended/Revoked/Cancelled Driving on Wrong Side of the Road Dropping Material on Roadway Equipment Violation Failure to Yield False Accident Report/Perjury Felony with a Motor Vehicle Fleeing or Eluding a Police Officer Homicide or Assault with a Motor Vehicle Illegal Possession of Alcohol/Drugs Illegal Transportation Improper Passing Leaving the Scene of an Accident Left of Center Loss of Physical Control/Intoxication Open Bottle Operate Vehicle in Unsafe Conditions Operating a Vehicle without Owner's Consent Other - Moving Violation Overweight Violation Passed Stopped School Bus Reckless Driving Refuse Chemical Test Speed Speeding 10 MPH or < 35-55 Speeding > 30 MPH over Posted Stop Sign Too Close Traffic Light Unverifiable Record Vio - Brake Req (Defective Brakes)
VEHICLE INFORMATION (All owned equipment MUST be listed)
Year
Make
Type
VIN
Stated Value
COVERAGE INFORMATION
Liability Limit $
350K CSL 500K CSL 750K CSL 1000K CSL Primary Non-Trucking ¾
Uninsured/M Limit $
75K CSL ¾ Other
Deductibles $
Specified Perils n/a 500 1000 2500 or Comprehensive n/a 500 1000 2500 Collision 500 1000 2500
Cargo Limit
All Risk Named Perils No Cargo ¾
Additional Insured
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