Trucking Application Ashlee

Trucking Long Form Application Ashlee

Trucking Long Form Application

Step 1 of 11

Name (and "dba")*
DOT Number*
Business Type
- Individual/Sole Proprietorship
- Partnership
- Corporation
- LLC
- Other
Select which type of business you are setup as.
Phone*
Email*
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Premises and Garaging Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person to contact for inspection (name and phone number)

Description of operations
Describe your business
Please give us a good description of your business.
Number of years of experience
Please describe years of experience in running your current business or other related businesses.
Are you a new venture?
- Yes
- No
This also includes setting up a new DOT or re-establishing an old DOT that has been inactive.
Is this your primary business?
- Yes
- No
If no, please explain?
Are you seasonal?
- Yes
- No
If you are seasonal what months do you work?
Have you ever filed bankruptcy? If yes, when? Please explain the circumstances.
Gross receipts from last year?
Please provide gross receipts from last year.
Estimated gross receipts for the upcoming year?

Please check if you do any of the following. Do you?
- Pull double trailers?
- Pull triple trailers?
- Rent or lease your vehicles to others?
- Hire other vehicles for work?
If yes, attach a copy of rental or lease agreement used.
Max. file size: 98 MB.

Driver information
Driver information

Please provide all of the following: Driver's full name, DOB, Driver's license state and DL number, CDL type, years licensed in CDL and date of hire for each driver.
Upload a driver list here.
Max. file size: 98 MB.
Please include the following with the list. Years of CDL experience Date of hire No, of accidents and moving violations in the last five years.

Vehicle section
Schedule of vehicles

Please include the following for each tractor and trailer. Year, make, model and type (truck, tractor, trailer, etc.) VIN number, Gross vehicle weight (GVW) Annual mileage per vehicle and also the radius of operation.
Please upload list of vehicles here if easier.
Max. file size: 98 MB.
Please include date purchased, cost when purchased, any permanently attached equipment to be covered, and total stated amount to be insured for for each unit.

Loss section
Have you had any losses in the last 4 (four) years?
- Yes
- No
If yes, please explain the loss

Make sure to include the date, amount paid and description of the loss.
Attached hard copy Loss runs from your prior carrier here
Drop files here or

Max. file size: 98 MB.
Please include loss runs for each carrier over the last 3 years.

Filing Information
Please check if these apply to your company. Do you?
- require a FHWA filing?
- require a FHWA cargo filing?
- require a MCS-90 filing?
If yes, what is your MC number?
If you hold a broker's license, indentify name filed with FHWA, FHWA docket no. and receipts from brokerage operations?
If you are an interstate regulated carrier, identify your registration or base state.

What state is your home base state and you are filed out of?
Is an intrastate filing needed?
- Yes
- No
If yes, show state and permit number. Also list states for which you need cargo filings if any.
What is your DOT number?
Will our policy cover all vehicles owned, operated, or under lease to your company?
- Yes
- No
If no, please explain why?

Please check if any of the following apply to your company. Have you?
- Ever changed your operating name?
- Operate under any other names?
- Operate as a subsidiary of another company?
- Own or manage any other transportation operates that are not covered?
- Lease your authority to others?
- Appoint agents or hire independent contractors to operate on your behalf?
- Purchased, sold or applied for authority over the last three years?
- Lost or had authority withdrawn. or have your been/are under probation by any regulatory authority? (FHWA, PUC, etc.)?
Please explain any "checked boxes" to the filing section above.

Do you have agreements with other carriers for the interchange of equipment or transportation of loads?
- Yes
- No
If yes, attach a copy of current agreements and answer the following: With whom has such agreements been made? Do they carry auto liability coverage? Do you carry a hold harmless agreement?
Do you barter, hire or lease any vehicles?
- Yes
- No
If yes, please explain.

Who is your current insurance company?
How much do you pay annually?
What is the total insurance cost currently you are paying with your current company?
Attached a copy of your current insurance and any renewals you have from your current insurance company.
Drop files here or

Max. file size: 98 MB.
Consent
I agree to the following:
No coverage is bound until the company advises the applicant or its representative that a policy will be issued and then only as of the policy effective date and in accordance with all policy terms. The Applicant acknowledges taht the Applicant's representative named below is acting as applicant's agnet and not on behalf of the company. The applicant's representative has no authority to bind coverage, may not accept any funds for the company, and may not modify or interpet the terms of the policy.
The applicant agrees that the foregoing statements and answers are true and correct. The applicant request the company to rely on its statements and answers in issuing any policy or subsequent renewal. The applicant agrees that if its statements and answers are materially false, the company may rescind any policy or subsequent renewal it may issue.
If any jurisdiction in which the Applicant intends to operate or the Federal Highway Administration requires a special endorsement to be attached to the policy which increases theCompany's liability, theApplicant agrees to reimburse theCompany in accordance with the terms of that endorsement.
The Applicant agrees that any inspection of autos, vehicles, equipment, premises, operations, or inspection of any othermatter relating to insurance that may be provided by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant or any other party in any respect.
The Applicant understands that an inquiry may be made into the character, finances, driving records, and other personal and business background information the Company deems necessary in determining whether to bind or maintain coverage. Upon written request, additional information will be provided to the Applicant regarding any investigation.
The Applicant represents that she/he has completed all relevant sections of this Application prior to execution and that the Applicant has personally signed below (or if Applicant is a Corporation, a corporate officer has signed below).

Would You Like Us To Review Your Policies?

1Products

2Contact Info

3Location

4Documents

5Final Comments

Hello! What would you like a quote for?*
- Business
- Business Property
- Cargo
- Commercial Trucking
- Group Benefits
- Life
Check all that apply. You can tell us if there is something else you need a quote for in just a moment.

Primary Policyholder Name*
First Last
Phone*
Email*

Insured Location Address*
Street Address Address Line 2 City State ZIP Code

This is not required, but if readily available, please upload your most current insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider (if you have a login), or from your current agent.
Drop files here or

Max. file size: 98 MB.

What led you to request this quote?*
- Internet Search
- Facebook Search/Page
- Referral
Who referred you to us?*
If you have any other questions, comments or requests, please leave them here

Trucking Long Form Application Ashlee

Step 1 of 11

Description of operations

Driver information

Vehicle section

Loss section

Filing Information

Would You Like Us To Review Your Policies?

Request Your Proposal Here