Trucking Long Form Application Sabo Trucking Application -NBCS- Trucking Long Form Application Step 1 of 11 9% Company Name (and "dba")*What is your DOT number?Business Type Individual/Sole Proprietorship Partnership/LLP Corporation LLC Other Select which type of business you are setup as. Contact Name*Phone*Email* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where you receive Mail.Premises and Garaging Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where your vehicles are parked/stored while not in use. Description of operationsDescribe your businessWhat commodities do you haul? What is your radius of operations? Number of years in Business?Please describe years of experience in running your current business or other related businesses. Are you a New Venture? Yes No Is this your Primary Business? Yes No If no, please explain? Do you operate over a regular route? Yes No Do you haul "for hire"? Yes No Do you operate in more than one state?* Yes No If yes, please list states entered.What are the largest cities you enter? List all types of Cargo hauled:Are you a Common Carrier? Yes No Are you a Contract Hauler? Yes No If yes, for whom?Do you haul any Hazardous Substances or Hazardous Materials as defined by the EPA? Yes No If yes, provide complete listing identifying all material(s) and/or chemical content. Do you pull Double Trailers? Yes No Do you haul your own Cargo exclusively? Yes No If not, who owns it?Do you rent or lease your vehicles to others?YesNoIf yes, attach a copy of rental or lease agreement used.Do you hire any vehicles?YesNo Driver informationDriver 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.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 sectionWill our policy cover all vehicles owned, operated or under lease to your company?* Yes No 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.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 experienced any Accidents in the last Three Years?* Yes No If yes, please explain the Loss.Make sure to include the date, amount paid and description of the loss. Have you had any Moving Violations in the last Three Years?* Yes No If yes, please explain the Violation.Attached hard copy Loss runs from your prior carrier here Drop files here or Please include loss runs for each carrier over the last 3 years. Filing InformationIs an MCS 90 Endorsement needed? Yes No If yes, what is your MC Number?Do you require FHWA Cargo Filings? Yes No 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. Have you ever changed your Operating Name? Yes No Do you operate under any other names? Yes No If yes, what other names?Do you Lease your Authority? Yes No Have you ever lost or had authority withdrawn, or have you been/are under probation by any regulatory authority (FHWA, PUC, etc.) ? Yes No Please explain any "yes" answer to the filing section above. Do you Hire, Lease or Barter any Vehicles? Yes No If yes, please explain.Attached a copy of your current insurance and any renewals you have from your current insurance company. Drop files here or 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).