* Agency Name:    

* Agency #:

Agency Contact:

E-Mail:                

GENERAL INFORMATION

* Principal Owner’s Name:

* Street Address:

* City: * State: * Zip code:  *County:

New Venture:Yes    No       

If New Venture, who did they drive for:

* Years in Business:    * Type of Business:

* Are Filings Required:Yes    No   

If Yes, List:

* Radius:    DOT #:    MC #:

* Specific Commodities Hauled: (General Freight not ACCEPTABLE)  

If hauling autos, answer the following questions:

How many years experience hauling autos:     With whom:

How many autos can be transported at one time:     Are any luxury, classic or other vehicles valued over $75,00 transported: Yes No If Yes, explain:

COVERAGE LIMITS

Limits of Liability:Select One25/50/2550/100/25100/300/100100,000300,000350,000500,000750,0001,000,000* Other    *Other:

Un-Insured Motorist:Select One25/50/2575,000100,000* OtherReject    *Other:

Med Pay:Select One100020005000None

MOTOR TRUCK CARGO

 Limits per Unit:    Deductible:

Is Reefer Breakdown Coverage Desired:Yes    No

TRUCKERS GL

Limits of Liability None1,000,000/1,000,0001,000,000/2,000,000

Is There Any Other Exposure Than Trucking: Yes    No

If Yes, explain:

SCHEDULE OF EQUIPMENT

Unit - 1

* Year                        * Make                                                   * GVW                  * Type                                                                             

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:     Deductible:

Unit - 2

 Year                           Make                                                    GVW                       Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *   

Value:     Deductible:

Unit - 3

 Year                                         Make                                                                   GVW                          Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

Unit - 4

 Year                                 Make                                               GVW                      Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

Unit - 5

 Year                                  Make                                               GVW                     Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

DRIVER INFORMATION & VIOLATIONS

Driver -1               * Name                                  * DOB             * Yrs Exp   * Hire Date  

* Minor Violations  Select OneNone12345        * Major Violations  Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -2                  Name                                    DOB          Yrs Exp      Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -3                     Name                               DOB           Yrs Exp      Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -4                    Name                                      DOB            Yrs Exp       Hire Date  

Minor Violations Select OneNone12345        Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -5                   Name                                   DOB          Yrs Exp      Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

PRIOR CARRIER INFORMATION

*Do You Have Current Coverage:             Select OneYesNoNew Venture

What Are The Effective Dates of Your Most Recent Policy:

Who Was The Carrier For The Prior Two Years:

LOSS HISTORY

* Have There Been Any Losses In The Last Three Years:Select OneYesNoNew Venture

If Yes, Explain

            Date                                                             Details                                                      Driver Involved                                 Line Of Coverage

ADDITIONAL INSTRUCTIONS OR COMMENT

Comments: