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Producing Agency:
Producer:
Producer's Email:
Insured Information
*Name of Applicant:
Email:
DBA:
*FEIN/SS#
Phone:
*Mailing Address:
*City:
*State:
*Zip:
*Garaging Address:
*City:
*State:
*Zip:
Underwriting Questions
1) Commodities Hauled and Percentage:
Commodities Hauled
Percentage
*
*
2) Has risk been canceled or non-renewed in the last 3 years?
Yes
No
3) How many years has insured owned commercial equipment?
4) Are filings needed?
Yes
No
4A) If Yes, what State(s)?:
5) Does the insured broker loads for others?
Yes
No
6) Cities traveled in/through:
City
% of Time
*
*
Driver Information
Driver Name
DOB
MM/DD/YY
# YRS. COMM
Driving Exp.
Last 3 years, # of VIOLS
Last 3 years, # of ACCS
*
Vehicle Information
Year
Make
Model
Value
Radius Range
*
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Tractor:
Trailer:
[Select]
Local
Intermediate
Int. Long
Unlimited
Loss Information
Previous carrier and loss information for last three years
Policy Dates
Company
Policy Number
# of Claims
Amount Paid
Type of Claim
*
Coverage and Limits
Requested Eff Date:
Needs Quote By:
Liability Limit:
Liability:
Primary
Non-Trucking
UM/UIM:
Physical Damage Deductible:
Cargo Limit:
Cargo Deductible :
Include Refer. Malfunction:
Yes
No
Additional Information:
Please attach pertinent files. If more than 4 attachments are needed, please click
here
to email them.
Attachment:
Attachment 2:
Attachment 3:
Attachment 4:
Name of Applicant:
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