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Who referred you?
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# of Trucks
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# of Trailers
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# of Drivers
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Applicant Information
Radius of Operations (%)
Auto Liability Coverage
Physical Damage Coverage
Comprehensive / Collision
Specified Perils / Collision
Motor Truck Cargo Coverage
Reefer Breakdown?
Additional Coverages
Hired Auto
Non-Owned Auto
Truckers GL (99793)
Trailer Interchange
Vehicle Schedule
Please Upload a Spreadsheet Containing Your Equipment List & Driver List
Upload Spreadsheet
Upload supported file (Max 15MB)
Drivers
** Employed drivers, including owner= E | Independent Contractors = 0
Cargo Carried
Operation History
Projected Year
Current Year
1 Year Prior
2 Years Prior
# of Power Units
Total Miles
Gross Receipts
Additional Questions
Does the applicant have any owed, leased operaed equipment not listed onthe vehicle schedule?
Yes
No
Are any vehicles leased, loaned or rented to others?
Yes
No
Has the applicant's policy canceled or non-renewed in the prior 3 years?
Yes
No
Please upload the following documents:
Past 5 Years of loss runs
Upload File
Past 4 Quarters of IFTA
Upload File
Current Policy
Upload File
Submit
Thank you! We’ll be in touch.
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