Company Information
Company
*
Company Type
*
Please Select
LLC
Corporation
Individual
Partnership
Business Type
*
Please Select
Commercial Trucker
Business Class
*
Please Select
Agricultural
Dirt, Sand and Gravel
General Freight/Other
Logging/Wood Chips
Refrigerated Goods
Auto Hauler
Coal
Containers
Debris Removal
Escort Vehicles
Expediters
Fracking, Sand or Water
Garbage & Trash
Hazardous Materials/Placards
Hotshot Transport
Household Goods Mover
Livestock
Machinery &Heavy Equipment
Mobile Home Toter
Oilfield Materials
Scrap Metal/Scrap Auto
Steel
Effective Date
*
/
Month
/
Day
Year
Date
DOT
*
Years In Business
*
FEIN
Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Garage Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Description of Operations
Contact Information
Owner
*
First Name
Last Name
Owner Date of Birth
*
-
Month
-
Day
Year
Date
Last 4 of SSN
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Expiring Premium
Target Premium
Quoting Information
ELD Provider
Top States Traveled too:
Average Length of Haul
*
Farthest Distance Traveled
*
Please Select
100
200
300
500
600
700
800
900
1000
1100
1200
1300
1400
1500
Radius of Operations: Breakdown of Mileage
*
Rows
0-50
51-200
201-300
301-600
Over 600
Percent
Historical and Projected Exposure Information:
Rows
Trucks
Mileage
Revenue
Projected:
Current:
1st Prior
2nd Prior
Auto Liability Limit
*
Please Select
$750,000
$1,000,000
$1,500,000
$2,000,000
General Liability Limit
*
Please Select
$1,000,000/$1,000,000
$1,000,000/$2,000,000
Trailer Interchange Limit
*
Please Select
$15,000
$20,000
$30,000
$40,000
$45,000
$60,000
Not Needed
Physical Damage/Trailer Interchange Deductible
*
Please Select
$1,000
$2,500
$5,000
Cargo Limit
*
Please Select
$50,000
$100,000
$150,000
$200,000
$250,000
Cargo Deductible
*
Please Select
$1,000
$2,500
$5,000
Commodities
Please be sure Commodity % adds up to 100%.
Commodity Type 1
*
Commodity % 1
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
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84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Commodity Type 1 Average Value
*
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 1 Max Value
*
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 2
Commodity % 2
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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85
86
87
88
89
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91
92
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95
96
97
98
99
100
Commodity Type 2 Average Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 2 Max Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 3
Commodity % 3
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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16
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98
99
100
Commodity Type 3 Average Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 3 Max Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 4
Commodity % 4
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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25
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28
29
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51
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80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Commodity Type 4 Average Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
Commodity Type 4 Max Value
Please Select
$5000
$10000
$15000
$20000
$25000
$30000
$40000
$50000
$60000
$70000
$80000
$90000
$100000
$110000
$120000
$130000
$140000
$150000
$160000
$170000
$180000
$190000
$200000
General Questions
*
Rows
Yes
No
Do you haul oversize, overweight loads?
Do you allow passengers?
Do you use team, hot seat, slip seat or relay driver operations?
Has any insurance company cancelled or non-renewed your insurance in the past 3 years?
Do you pull Doubles and/or Triples?
Do you Transport any hazardous materials?
Do you lease onto another carrier?
Any moving or non-moving violations in the past 3 years?
Are any autos registered or garaged outside of the state you are domiciled?
Any drivers with less than 2 years of
experience?
Is the customer currently insured with Progressive?
Do you act as a freight forwarder, broker, or arrange loads for others?
Does a bobtail liability exposure ever exist?
General Questions
*
Rows
Yes
No
Is all commercial equipment on the application?
Is the customer currently insured?
Has the customer had continuous coverage?
Do you have a vehicle maintenance program?
Do you participate in a drug testing program?
Do your driver files conform to DOT requirements?
Do you utilize PSP(Pre-Employment Screening) as part of your hiring process?
Does the customer have other coverages for the business?
Does the customer have a US DOT?
Is a Blanket Additional Insurance endorsement needed by contract?
Is a Blanket Waiver of Subrogation Endorsement needed by contract?
Do all drivers get road tested?
General Questions
*
Rows
Yes
No
Are your trucks equipped with speed governors?
Is there a written driver safety program?
Have you had any claims in the last 2 years?
Do you haul refrigerated loads?
Have you had any claims in the last 2 years?
Any routes require overnight stays?
Are vehicles governed?
General Questions
*
Rows
Yes
No
Do you engage in any residential deliveries?
Is any portion of your operation seasonal?
Do you operate mobile equipment subject to compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged?
Do you require use of escort vehicles?
Do you haul to/from well drilling sites or mines?
Do other motor carriers or owner-operators haul for you?
Do you lease your power units to others?
Driver Information
Vehicle Information
Please add Loss Runs and last 4 quarters of IFTA
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