Enter DOT numberDOT number* General InformationFull Name: [lead return="last_name"] Date: [lead return="f_date"] Home Address: [lead return="f_address_primary"] Garaging Address: [lead return="f_address_alt"] Phone: [lead return="phone_work"] Email: [lead return="email1"] TRUCKING Company: DOT #: [lead return="dot_c"] MC: [lead return="mc_c"] FEIN: FEIN:*MC:Quote applicantName* First Last Email* Phone*Insurance InformationQuote expected date* Date Format: MM slash DD slash YYYY Quote expected date is not guaranteed.Proposed Effective Date* Date Format: MM slash DD slash YYYY All coverages expires on the same day Existing Policy expiration date* Date Format: MM slash DD slash YYYY Insurance needed*Mark all that is needed. Primary Auto Liability Non Trucking Liability Physical damage MT Cargo General Liability TruckingActive Carrier Authority?* YesNoType of LoadsGeneral FreightHousehold GoodsMetal: sheets, coils, rollsMotor VehiclesDrive/Tow awayLogs, Poles, Beams, LumberBuilding MaterialsMobile HomesMachinery, Large ObjectsFresh ProduceLiquids/GasesIntermodal ContainersPassengersOilfield EquipmentLivestockGrain, Feed, HayCoal/CokeMeatGarbage/RefuseUS MailChemicalsCommodities Dry BulkRefrigerated FoodBeveragesPaper ProductsUtilitiesAgricultural/Farm SuppliesConstructionWater WellGarage address Street Address Additional Trucking infoHas applicant operated Trucking company under another DOT /MC #* YesNoPrevious DOT*Date operations started under previous DOT* Date Format: MM slash DD slash YYYY Date operations ended under previous DOT* Date Format: MM slash DD slash YYYY Maximum radius of operations in milesDescription of operationsPlease describe your daily operations. You can also enter type of loads that are not preselected.Notes Trucks and DriversVehiclesIn this section we will add your trucks and trailers if you have them. To do that, click the Add a Vehicle button below, complete the required fields and then click the Save Vehicle button. If you need to make changes to an existing driver, click the edit button or delete button to delete the driver and start over. When you are done adding your vehicles, click the Next button to continue. Type VIN Year Make Stated Value DriversIn this section we will add you as a driver on this policy. To do that, click the Add a Driver button below, complete the required fields and then click the Save Driver button. If you need to make changes to an existing driver, click the edit button or delete button to delete the driver and start over. When you are done adding your drivers, click the Next button to continue. Name Date of Birth License # State Please check to confirm* I confirm that information above is accurate.I understand that coverage will be jeopardized if information will be misrepresented. Primary Auto Liability (ATL)Primary Liability Insurance coverage protects you from damage or injuries to other people as a result of a truck accident. This truck insurance coverage is mandated by state and federal agencies and proof of coverage is required.ATL coverage expiration Date Format: MM slash DD slash YYYY ATL limits required* $300,000$750,000$1,000,000OtherATL Deductible* $0$1,000$2,500$5,000$10,000$25,000$50,000Other (ATL limit required)* ATL Uninsured Motorist (UM) required UM/UIM is a policy level coverage that provides coverage for damages which an insured is legally entitled to recover from another party who is considered at-fault for an accident, but is uninsured or underinsured for the level of damages. ATL hired non owned coverage required Hired Auto provides liability coverage for hired (rented, leased or borrowed) vehicles occasionally used for the insured's business. ATL Personal Injury (PIP) required PIP coverage provides payments for appropriate benefits if an insured, or other persons covered under the policy, is injured in an accident. PIP has three parts - (1) medical benefits: coverage for the cost of treatment the insured receives from hospitals, doctors and other medical providers; (2) disability benefits: reimbursement for certain expenses that result from injuries, such as lost wages or any reasonable expenses incurred in obtaining services from others during a period of disability; and (3) death benefits: benefits payable if an insured dies because of bodily injury sustained in an accident. ATL Medical Payments required Med Pay provides coverage for certain medical and funeral expenses for all those occupying a covered vehicle involved in an accident regardless of who is at-fault. Non Trucking Liability (NTL)NTL coverage expiration Date Format: MM slash DD slash YYYY NTL limits* $300,000$750,000$1,000,000OtherOther (NTL limit)*NTL leased to nameCarrier name under whose authority vehicle is operatedNTL leased to MC numberCarriers MC number Physical Damage (PD)PD coverage expiration Date Format: MM slash DD slash YYYY PD deductible* $1,000.00$2,000.00$2,500.00$5,000.00$10,000.00 PD trailer interchange required PD Towing required PD trailer interchange coverage amount*PD Towing amount required*PD trailer interchange deductible* MT CargoCargo coverage expiration Date Format: MM slash DD slash YYYY Type of Trailers usedDry VanRefrigeratedFlatbedTankerCar CarrierBulk TrailerDump TrailerOtherBy clicking you can select multiple values.Cargo limit required* $100,000$200,000$250,000OtherOther (Cargo limit required)*Other (Type of Trailers used)*Max Value per Load $*Cargo deductible required* $1,000$2,500$5,000$10,000OtherOther (Cargo deductible required)*Is reefer breakdown required?* YesNoWhat % of incomes from Refrigerated Loads*What % of reefer loads from Total Loads* Cargo terminal coverage required Cargo terminal limit required* Has hazMat load What type of hazmat load do you deliver?* Truckers General Liability (GL)GL coverage expiration Date Format: MM slash DD slash YYYY GL limits required* $1,000,000/1,000,000$1,000,000/2,000,000$2,000,000/5,000,000OtherOther (GL limit required first part)*Other (GL limit required second part)*Last year company revenueTotal salary paid for last year Final Risk InformationAdditional informationPlease add information which can help us do better quote for youUpload File Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx. Please upload any other documents with value for the quote.NameThis field is for validation purposes and should be left unchanged.