Insurance Application

Rep Name *

Effective Date

USDOT Number

Organization

Type of Trucker

Full Name

Address

Date of birth

Phone

Type of Vehicle(s)

Vehicle List

Parking Zipcode

Farthest one-way distance this vehicle typically travels (90% or more of the time)

Driver List (Full Name, DOB, DL Number, CDL?, If so when issued? Any violations, claims, accidents?)

Coverages Needed (Check all that apply)

Potential Discounts (Check all that apply)

Proof of Prior Insurance (continuous coverage over 1 year - personal auto qualifies)

Smart Haul Discount (Already have Electronic Logging Device ELD)

Smart Haul Discount (Need ELD referral)

Notes