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Trucking Long Form Application Ashlee
Trucking Long Form Application
Step
1
of
11
9%
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaรงao
Cyprus
Czechia
Cรดte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Rรฉunion
Saint Barthรฉlemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Tรผrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
ร land Islands
Country
Premises and Garaging Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaรงao
Cyprus
Czechia
Cรดte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Rรฉunion
Saint Barthรฉlemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Tรผrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
ร land Islands
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?
Do you operate in more than one state?
Yes
No
If yes, please list states entered.
Do you haul for hire?
Yes
No
Show largest cities entered?
This will help us build a zone rating and provide the most competitive pricing!
Do you operate over a regular route?
Yes
No
If yes, show towns operated between.
Are you a common carrier?
Yes
No
Are you a contract hauler?
Yes
No
If yes, for whom?
List all types of Cargo hauled:
Do you haul any hazardous or extra hazardous substances or materials as defined by the EPA?
Yes
No
If yes, provide complete listing identifying all material(s) and/or chemical content.
Do you haul your own cargo exclusively?
Yes
No
If not, who owns it?
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
Select files
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
Select files
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).
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