Primary Contact Name*

First Last

Contact (Email)*

Contact (Phone)*

Legal Business Name*

DBA

DOT Number

Years in Business*

Effective Date for Policy*

Business Information

Mailing Address*

Street Address City State ZIP Code

Garaging Address*

Same as Mailing Address

Shipping Address*

Same as Mailing Address

Federal Filings

Y

N

State Filings

Y

N

Previous Insurance Cancelled or Non-Renewed

Y

N

Type of Operations

Local Trucker*

Y

N

Intermediate Trucker*

Y

N

Long Haul Trucker*

Y

N

Intermodal or Port Trucker*

Y

N

Radius of Operations

Total percent of all 4 radius options below must add up to 100%.

Percent 0-50 Miles*

Percent 51-200 Miles*

Percent 201-500 Miles*

Percent 500+ Miles*

Percent Total Radius

Vehicles & Trailers

Total Number of Vehicles*

Enter 0 if no vehicles

Total Value of Vehicles

Total Number of Trailers*

Enter 0 if no trailers

Total Value of Trailers

Vehicle Information

Vehicles List*

VIN

Year

Make

Model

Value

Class Key

Deductible

Trailer Information

Trailers List

VIN

Year

Make

Model

Value

Body Type Key

Driver Information

Please make sure to include yourself if you are a driver.

Do all drivers have at least 2 years CDL experience?*

Y

N

Drivers List

If you are a driver, remember include yourself. Date of Birth format must be MM/DD/YYYY.

First Name

Last Name

License Number

License State

Date of Birth

Eligibility

Commodities

Combined percent of all commodities must equal 100. This is a large list below. Just leave commodities blank that you do NOT haul.

Agricultural Equipment

Alcoholic Beverages

Appliances

Arms, Ammunition, Fireworks

Automobile Parts and Accessories

Automobiles (5 or Less)

Automobiles (6 or More)

Beer and Wine

Beverages

Building Materials

Bulk or Bagged Nuts

Cameras and Film

Cannabis and CBD

Canned Goods

Cement, Sand, or Gravel

Chemicals (Packaged or Bulk)

China and Ceramics

Cigarettes and Cigars

Clothing

Coal

Computers

Contractors Heavy Equipment

Cosmetics and Perfume

Cotton

Courier Documents

Cranes

Currency

Dairy Products

Dangerous Articles, Explosives, Corrosives, Flammables

Department Store Goods

Documents

Drugs

Dry Goods

Eggs

Electrical Supplies and Fixtures

Empty Trailers

Farm Products

Fertilizer

Fine Arts

Food Products

Fracking

Frozen or Refrigerated Products

Furniture

Furs

General Merchandise

Glassware

Grain, Hay, Feed

Hanging Meat

Hardware and Paint

Hazmat

Household Effects

Household Goods

Intermodal Containers

Jewelry

Ladies and Mens Dress Apparel

Leather Goods

Liquid Haulers

Livestock and Live Poultry

Logs

Lumber

Light Machinery

Machinery and Heavy Equipment

Meat

Metal and Steel

Mobile Homes

Narcotics

Non-Ferrous Metal

Nursery Plants, Trees, Flowers

Office Equipment

Paper and Paper Products

People

Petroleum Products

Pipe, Cable, and Wire

Plumbing Supplies

Plastic and Plastic Products

Poultry

Power Tools

Precious Metals

Produce

Recreational Vehicles, Boats, RVs

Refuse Garbage

Rugs and Carpets (Oriental)

Rugs and Carpets

Scrap Metal

Seafood (Canned)

Seafood (Fresh)

Seafood (Frozen)

Seafood (Shellfish)

Seafood

Shoes

Specialized Heavy Haulers

Sporting Goods and Toys

Textiles

Tires and Tubes

Tobacco

TV, Radios and Stereo Equipment

Video Equipment and Tapes

Total Percent of Commodities

Error: Commodities total More Than 100%. Please adjust your chosen commodities above.

Prior Loss History

Past 3 years of loss history is needed if not a new venture.

Any prior losses or claims*

Y

N

Year 1: Any Prior Losses?*

Y

N

Year 2: Any Prior Losses?*

Y

N

Year 3: Any Prior Losses?*

Y

N

Year 1 Losses

This is last year

Year 1: # of Auto Liability Losses

Year 1: # of Physical Damage Losses

Year 1: # of Cargo Losses

Year 1: # of Truckers GL Losses

Year 1: Liability Amount Paid

Year 1: Physical Damage Amount Paid

Year 1: Cargo Amount Paid

Year 1: Truckers GL Amount Paid

Year 2 Losses

This is 2 years ago.

Year 2: # of Auto Liability Losses

Year 2: # of Physical Damage Losses

Year 2: # of Cargo Losses

Year 2: # of Truckers GL Losses

Year 2: Liability Amount Paid

Year 2: Physical Damage Amount Paid

Year 2: Cargo Amount Paid

Year 2: Truckers GL Amount Paid

Year 3 Losses

This is 3 years ago.

Year 3: # of Auto Liability Losses

Year 3: # of Physical Damage Losses

Year 3: # of Cargo Losses

Year 3: # of Truckers GL Losses

Year 3: Liability Amount Paid

Year 3: Physical Damage Amount Paid

Year 3: Cargo Amount Paid

Year 3: Truckers GL Amount Paid

Additional Comments

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How were you referred to us?

All the above information is accurate and true to the best of my knowledge.*

Yes

Email

This field is for validation purposes and should be left unchanged.

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Greenwood Office

Indianapolis Office

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Indianapolis Office

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Driver Information

Commodities

Coverage Options

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Prior Loss History

Year 1 Losses

Year 2 Losses

Year 3 Losses

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