Trucking Insurance Application Trucking Application Ryan VTI (2) "*" indicates required fields 1Business2Operations3Fleet4Coverage COMPANY INFORMATIONBusiness legal name*DOT number*Enter ‘PENDING’ if not issued yet.MC number (optional)EIN / FEIN (Required)*DBA?* Yes No DBA name*CONTACT INFORMATIONFirst name*Last name*Mobile number*Email* Text updates?* Yes No We only text about your quote. CURRENT INSURANCEDo you currently have trucking insurance?* Yes No Policy end date MM slash DD slash YYYY Upload dec page (recommended)Max. file size: 98 MB. If you’re not sure of the end date, upload this.Requested start date (optional) MM slash DD slash YYYY OPERATIONSOperation type(s)* Dry Van Refrigerated (Reefer) Flatbed Intermodal / Container Tanker Bulk / Dump Other Other (describe)How do you operate? (check all that apply)* For-hire (haul for others) Private carrier (haul your own goods) Multi-state / Interstate Hazmat Contract / Dedicated New venture (new authority) States entered*Example: CA, AZ, NVWhat type of hazmat?*Example: fuel, chemicals, batteriesCustomer name (contract/dedicated)*How long have you had authority?*How long have you had authority?0–3 months4–12 months1–2 years2+ yearsLOCATION & RADIUSGaraging ZIP Code*Where the truck is primarily kept overnight.Garaging StateGaraging StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingRadius of Operation*Radius of OperationLocal (0–50 miles)Intermediate (51–200 miles)Regional (201–500 miles)Long Haul / OTR (501+ miles)Top 3 Drop offs FILINGSDo you need help with State Filings? Yes No Check if applicable to your company MCS-90 Intrastate Filings State Cargo Filings COMMODITIESCommodity info method* Upload list (recommended) I’ll type it Upload commodity list*Max. file size: 98 MB. A screenshot/photo is okay.Commodities*Describe each type of Cargo Hauled% of HaulingAverage Value of LoadMax Value of Load Add RemoveFLEET COUNTSNumber of Drivers*Number of Trucks / Power Units*Number of Trailers*DRIVERSHow would you like to provide driver info?* Upload driver list (recommended) I’ll enter drivers manually Upload driver list*Max. file size: 98 MB. A screenshot/photo is okay. Include name + DOB + license state/number (if available).Drivers (manual entry)*First and Last NameDate of BirthDriver's license state and DL numberYears of CDL experienceHire date Add RemovePlease select the hiring practices you employ for new hires. PSP *Pre Employment Screening Background Check Pre hire Drive Test Drug Screening All drivers have 2 years or more of CDL experience Please go over Driver Management procedures and training processes. CLAIMSAny claims in the last 5 years?* Yes No Loss details*Date + amount + short summary.Upload loss runs (optional)Max. file size: 98 MB. VEHICLESHow would you like to provide vehicle info?* Upload vehicle schedule (recommended) I’ll type it Upload vehicle information*Max. file size: 98 MB. Registration, list, or dec page is fine.Vehicles (manual entry)*Vehicle YearMakeModelVINValue Add RemovePlease describe your vehicle maintenance programCOVERAGESCoverages to quote* Auto Liability Cargo Physical Damage (Comp/Collision) General Liability Other Other coverage requestedContract requires specific limits? Yes No Upload contract/requirementsMax. file size: 98 MB. Are you the only financial responsibility? Yes No Owner's Name or Financial responsibility First Last Owner's Date of Birth MM slash DD slash YYYY CONSENTConsent* I agree to the privacy policy.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 that the Applicant's representative named below is acting as applicant's agent 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 interpret 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 other matter 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).
