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*Required
Dated
Dated is required
*Individual Name / Owner
First Name is required
*Phone
Phone is required
*Email
Email is invalid
D/B/A
Garage Address (Where you park your trucks):
Address Line One
Address Line Two
City
State
-Select-
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
*Coverage Needed:
Primary Coverage
Non-Trucking(Bobtail) and Physical Damage
Coverage is required
Liability Limits:
Amount
- Amount -
$1,000,000
$750,000
Other
Cargo limit amount
- Amount -
$100,000
$50,000
Other
Deductible
- Amount -
$1,000
$2,500
Federal Motor Carriers and Department of Transportation Carriers:
MC#:
DOT#:
Other Coverages:
Non-Owned Trailer / Trailer Interchange Limit
General Liability
Radius
- Miles -
Unlimited Miles
500 Miles
300 Miles
States Traveled
Cities Traveled
Commodities / Cargo hauled:
#1
%
Value of Avg Load
Max Value of Load
#2
%
Value of Avg Load
Max Value of Load
#3
%
Value of Avg Load
Max Value of Load
#4
%
Value of Avg Load
Max Value of Load
Years in Business
Current Policy Expiration Date
Vehicle Schedule:
#1 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#2 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#3 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#4 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#5 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#6 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#7 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#8 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#9 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
#10 Year
Make/Model
GVW
Value
Deductible
- Amount -
$1,000
$2,500
Driver Info:
#1 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#2 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#3 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#4 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#5 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#6 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#7 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#8 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#9 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
#10 Name
DOB
Yrs w/ CDL
Date of Hire
Violations
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