EmailThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type:(Required) Individual Partnership Corporation LLC Joint Venture Other Applicant Name(Required)Applicant's Name(Required) First Last Applicant's Company Name(Required)(N/A if you don't have one)Owner's Name(Required) First Last Business Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is business address the same as mailing address?(Required) Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)FaxEmail Address(Required) Website FEIN (Tax ID #)(Required)Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)Please describe the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any vehicles that have been customized, altered, or that have special equipment?(Required) Yes No If yes, please describe:(Required)Are there any vehicles leased to others?(Required) Yes No Annual Revenue:(Required)Total Number of Employees:(Required)Number of Full Time Employees:(Required)Number of Part Time Employees:(Required)Number of Contractors:(Required)What are your standard operating hours?(Required)Total number of vehicles to be insured:(Required)Do vehicles transport hazardous materials?(Required) Yes No If yes, complete the following:a) Does applicant have a written emergency spill plan for drivers?(Required) Yes No b) Is applicant registered to haul hazardous materials?(Required) Yes No c) Does applicant deliver products to rail yards, marinas, or airports?(Required) Yes No d) Does applicant unload directly onto the trains, watercraft, or aircraft?(Required) Yes No e) Are drivers trained to handle the hazardous materials using the proper equipment?(Required) Yes No Are vehicles equipped with GPS tracking or telematics?(Required) Yes No Please specify provider:(Required)OperationsWhat is the typical operating radius of your vehicles from your primary business location? (e.g., local, regional, interstate):(Required)Do vehicles cross state lines or international borders?(Required) Yes No Which states/countries?(Required)Are there any other business operations or services provided that are not directly related to the primary activity, especially those involving vehicle use?(Required) Yes No Please describe other operations:(Required)Vehicle InformationHow many commercial vehicles are owned or leased by the applicant for business purposes?(Required)Please provide details for each vehicle below:List(Required)YearMakeModelVINOwned or Leased?Usage Type (Delivery, Service, etc.)Est. Annual MileageGarage Location (City, State) Add RemoveAre all vehicles registered under the applicant's name?(Required) Yes No If no, please explain:(Required)Are any vehicles equipped with specialized equipment (e.g., refrigeration units, lift gates, trailers)?(Required) Yes No If yes, please explain:(Required)Are vehicles regularly maintained?(Required) Yes No If yes, how often?(Required)Vehicle Use & OperationsWhat is the primary use of vehicles (e.g., service, delivery, sales, farm use, personal use by owner/employee, long-haul trucking, public livery)?(Required)This is critical for rating. If there are multiple uses, please describe percentage of each use:What is the Estimated Annual Mileage?(Required)Where is/are the vehicle(s) primarily parked when not in use?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is it a secure location (e.g., locked lot, garage)?(Required)Is/Are the vehicle(s) owned, leased, or financed?(Required) Owned Leased Financed If financed/leased, what is the lienholder/lessor's name?(Required)What is the leainholder/lessor's address?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the lien amount?(Required)Are there any permanently attached or custom-built features (e.g., custom shelving, toolboxes, liftgates, snow plows, special bodies)?(Required) Yes No If so, please list the feature and its value:(Required)Permanent/Custom FeatureValue Add RemoveWhat type of goods or materials are typically transported in this vehicle? Are they hazardous, perishable, or high-value?(Required)Do employees or contractors use personal vehicles for business purposes?(Required) Yes No If yes, how often and for what purposes?(Required)Do you own any mobile equipment or operate any mobile equipment off premises?(Required) Yes No If yes, please describe:(Required)Driver InformationPlease list all drivers:(Required)Full NameDOBLicense #State of IssueLicense ClassYears of Exp Add RemoveMotor Vehicle Record (MVR) History for Drivers: (please provide from DMV for a good driver discount, if applicable)Any at-fault accidents in the last 3-5 years? (Provide dates, details, and amounts if known):(Required)Any moving violations in the last 3-5 years? (e.g., speeding, reckless driving, DUI/DWI, distracted driving):(Required)Any suspensions or revocations of driver's license?(Required)Is any formal defensive driving or specialized training provided to drivers?(Required)Does the applicant have a drug and alcohol testing policy, especially for CDL drivers (DOT compliance)?(Required)How are drivers screened and vetted prior to employment? (e.g., MVR checks, prior employment verification)(Required)Are MVRs run periodically on existing drivers? How often?(Required)Are drivers required to report changes in their license status or personal driving record?(Required)Coverage & Policy InformationRequested Coverage Limits:Liability per occurrence:(Required)Liability aggregate:(Required)Collision per vehicle:(Required)Comprehensive per vehicle:(Required)Do you require uninsured/underinsured motorist coverage?(Required) Yes No Uninsured/Underinsured Motorist Limit:(Required)Hired & Non-Owned Auto Coverage:(Required) Yes No Medical Payments Coverage:(Required) Yes No Do you need physical damage coverage for company-owned vehicles?(Required) Yes No If yes, what is your preferred deductible?(Required) $500 $1000 Other Other amount:(Required)Would you like coverage for rental vehicles or hired/non-owned vehicles?(Required) Yes No Do you need cargo insurance for transported goods?(Required) Yes No If yes, what is the estimated value of cargo per trip?(Required)Would you like roadside assistance coverage?(Required) Yes No Would you like Additional Insured / Waiver of Subrogation?(Required) Yes No Safety & Risk ManagementDo you have a written fleet safety policy?(Required) Yes No If yes, please describe:(Required)Are there policies regarding cell phone use, distracted driving, fatigue management, and aggressive driving?(Required)Are drivers provided with safety equipment (e.g., reflective vests, cones, first-aid kits)?(Required) Yes No If yes, please describe:(Required)How often are vehicle inspections performed?(Required)Do drivers have access to 24/7 roadside assistance?(Required) Yes No How are vehicles maintained? (In-house mechanics, third-party repair shops, dealership service) please describe:(Required)What is the preventative maintenance schedule for all vehicles?(Required)Are vehicle logs kept? Are pre-trip and post-trip inspections conducted?(Required)What procedures are in place for drivers to follow in the event of an accident?(Required)How are accidents reported internally and to the insurer?(Required)Insurance History & Claims InformationDo you currently have commercial auto insurance?(Required) Yes No Name of current insurer:(Required)Current policy limits:(Required)Policy expiration date:(Required) MM slash DD slash YYYY Have there been any prior commercial auto claims, losses, or incidents (regardless of fault or if insurance paid) in the last five years?(Required) Yes No Please provide full details including dates, descriptions, amounts paid, and current status:(Required)Has any previous commercial auto insurance been declined, cancelled, or non-renewed?(Required) Yes No Please explain the circumstances:(Required)Additional Comments or Special ConsiderationsAdditional Comments or Special Considerations Δ
