APPLICATION

Commercial trucking application

For motor carriers and owner-operators. Have your USDOT number, equipment list and driver CDLs ready. Loss runs and a copy of your MCS-150 speed up the quote.

Business information

Legal business name

DBA, if different

Entity type

Years in business

Federal EIN Leave blank for a sole proprietor

Owner Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Contact name

Phone

Business address

City

State

ZIP code

Authority and operations

USDOT number

MC number Leave blank if you have not applied

Operating authority

Date authority was granted or applied for

Type of operation

Commodities hauled General freight, produce, steel, vehicles, hazmat

Hazardous materials?

Operating radius

States you operate in

Total annual miles, all units

Annual gross revenue

If leased on, name of the motor carrier

Coverage requested

Auto liability limit

Motor truck cargo

General liability

Physical damage on equipment

Non-trucking liability (bobtail)

Trailer interchange

Occupational accident for owner-operators

Filings required MCS-90, BMC-91X, Form E, Form H, UIIA

Shipper or broker contract requirements Limits, additional insureds, waiver of subrogation

Power units

Unit 1

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Unit 2

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Unit 3

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Unit 4

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Unit 5

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Unit 6

VIN

Year, make and model

Unit type

GVW or GCW (lbs)

Stated value

Ownership

Lienholder or lessor

Coverage wanted

Trailers

Trailer 1

VIN

Year and make

Trailer type

Stated value

Ownership

Trailer 2

VIN

Year and make

Trailer type

Stated value

Ownership

Trailer 3

VIN

Year and make

Trailer type

Stated value

Ownership

Trailer 4

VIN

Year and make

Trailer type

Stated value

Ownership

Trailer 5

VIN

Year and make

Trailer type

Stated value

Ownership

Trailer 6

VIN

Year and make

Trailer type

Stated value

Ownership

Drivers

Every driver with access to the equipment. Carriers will run MVRs.

Driver 1

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Driver 2

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Driver 3

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Driver 4

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Driver 5

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Driver 6

Full legal name

Date of birth

Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

CDL number

CDL state

Years holding a CDL

Date of hire

Moving violations or accidents in the last 3 years Date and type, or "none"

Loss history and prior insurance

Current or most recent carrier

Current annual premium

Policy expiration date

Claims in the last 3 years Date, type and amount, or "none"

When do you need coverage to start?

Loss runs, 3 years (optional) PDF under 4 MB

MCS-150 or authority letter (optional) PDF or image under 4 MB

Anything else

Notes for the agent Safety program, ELD, cameras, driver training, anything that helps your rate