Insured Information
Name
Address
City
State Zip
Desired Effective Date
# Years primary liability coverage under above name

1. Commodities Hauled
2. States Entered
3. Has risk benn cancelled or non-renewed in last 3 years? yes no
4. How many years has insured owned commercial equipment?

Driver Information
Driver Name
Date of Birth
Date Hired
# Yrs commercial Driving
Last 3 yrs of moving violations / convictions




Vehicle Information
Year
Make
Value Present
Radius Average
Radius Maximum

Top Four (4) Hauls
Pick up Drop off
Pick up Drop off
Pick up Drop off
Pick up Drop off

Coverage & Limits
Liability
Primary Liability Non-Trucking Liability
Auto Liability
750,000 1,000,000

Physical Damage
Collision
Other than collision

Cargo
Commodity Transported
% of Total Revenue
Maximum value per truck load
Cargo Deductible (s) 500 1,000 2,500