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INSURANCE APPLICATION

Is this a new venture or a renewal?
New Venture
Renewal
Owner DOB
Month
Day
Year

Insured Address (Business Address)

Multi-line address

Complete Garaging Address (where will your truck be parked) *

Multi-line address

Please enter a valid phone number.

Loss Payees/Lease?
Yes
No
Other

Vehicle Information

Vehicle #1

Type
Is this unit owned or a long term rental?
Owned
Long Term Renal
Other
Would you like to add another vehicle?
Yes
No

Driver Information

Type
Owner
Owner/Operator
Employee
DOB
Month
Day
Year
Does Driver have a CDL?
Yes
No
Would you like to add more drivers?

Trailer Information

Is this unit owned or a long term rental?
Owned
Long Term Rental
Would you like to add another trailer?
Yes
No

Description of Operations

Business Type
If tow truck, do you do repos?
Yes
No
Do you operate in more than one state? *
Yes
No
Do you haul hazardous material? *
Yes
No
Do you rent/lease your vehicles to others? *
Yes
No

Type of Insurance Requested

Do you currently have a commercial auto policy?
Yes
No
Select the coverages needed

Please list coverage limits $ needed

Desired Deductible? *
What kind of cargo are you hauling?

Applicant Questions

Do you require federal filings?
Yes
No
Date of Authority
Month
Day
Year
Does your company conduct any business or travels outside the state of your business state?
Yes
No
What mile radius will you be traveling?
100-300 miles
300-500 miles
500+ miles
Do your company vehicles haul double/triple trailers and/or oversized loads?
Yes
No
Has the applicant ever done business under a different name?
Yes
No
Will you be doing any residential deliveries moving furniture?
Yes
No

Certificate of formation & EIN paperwork

Do you currently have a personal auto policy?
Yes
No
How did you hear about us?
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