* Agency Name:    

* Agency #:

Agency Contact:

E-Mail:                

GENERAL INFORMATION

* Principal Owner’s Name:

* Street Address:

* City:    * State:    * Zip code:

New Venture:Yes    No       

If New Venture, who did they drive for:

* Years in Business:    * Type of Business:

* Radius:      

* Specific Commodities Hauled:(General Freight not ACCEPTABLE)  

SCHEDULE OF EQUIPMENT

Unit - 1

* Year                                    * Make                                          * GVW                   * Type                                                                                   

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

* Value:     * Deductible:

Unit - 2

Year                                     Make                                           GVW                   Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *   

Value:     Deductible:

Unit - 3

Year                                 Make                                                GVW                 Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

Unit - 4

Year                               Make                                                GVW                  Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

Unit - 5

Year                                Make                                                GVW                   Type

        Select One0 - 10,00010,001 - 20,00020,001 - 45,000Over 45,000  Select OneTractorTrailerWreckerRollbackTruckPick-UpOther *

Value:    Deductible:

DRIVER INFORMATION & VIOLATIONS

Driver -1                     * Name                                     DOB                  Yrs Exp       Hire Date  

* Minor Violations  Select OneNone12345        * Major Violations  Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -2                      Name                                     DOB          Yrs Exp       Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -3                         Name                                  DOB            Yrs Exp      Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -4                         Name                                  DOB            Yrs Exp      Hire Date  

Minor Violations Select OneNone12345         Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

Driver -5                       Name                                    DOB            Yrs Exp      Hire Date  

Minor Violations Select OneNone12345        Major Violations Select OneNoneDUIDrugsHit & RunReckless DrivingAny FelonySpeeding over 20mph

Accidents Summary:

Did major violation occur in private passenger or Commercial vehicle?   Select OnePrivate PassengerCommercial Vehicle

Please Give Details:

PRIOR CARRIER INFORMATION

*Do You Have Current Coverage:      Select OneYesNoNew Venture

What Are The Effective Dates of Your Most Recent Policy:

Who Was The Carrier For The Prior Two Years:

LOSS HISTORY

* Have There Been Any Physical Damage Losses In The Last Three Years:      Select OneYesNoNew Venture

If Yes, Explain

            Date                                                             Details                                                                  Driver Involved                                           

ADDITIONAL INSTRUCTIONS OR COMMENT

Comments: