Contact:
Company:
Type of Company:
Individual
Partnership
Corporation
LLC
LP
LLP
Phone:
Email:
Years in Bus. w/Own Insurance:
Current Insurance Company:
Expiration Date:
Liability Limit Required:
$500,000
$1,000,000
$5,000,000
Other
PIP Limit:
$2,500
$5,000
$10,000
Other Liability Limit:
Mailing Address:
Location Address:
States Traveled:
Commodities Transported:
Radius of Operation:
Average Length of Haul:
Annual Miles per Truck:
Example of Average Haul:
Large Cities Traveled:
Prior Insurance 3 years:
Uninsured Motorist:
Hired or Non Owned Auto:
Any losses in 5 years:
Comp Deductible:
Coll Deductible:
Cargo Limit Per Vehicle:
Cargo Deductible:
Hauling for Hire:
Explain if Hauling for Self:
Ever cancelled or declined:
TXDOT No:
ICC No:
Unit 1 thru 5:
Yr, Make, Model, VIN, Lic State, GVW,Owner, Max Radius, Ter or Max Zones, Date Purch, Current Value.
Unit 6 thru 10:
Yr, Make, Model, VIN, Lic State, GVW,Owner, Max Radius, Ter or Max Zones, Date Purch, Current Value.
Trailer 1 thru 5:
Yr, Make, Model, VIN, Lic State, GVW,Owner, Max Radius, Ter or Max Zones, Date Purch, Current Value.
Trailer 6 thru 10:
Yr, Make, Model, VIN, Lic State, GVW,Owner, Max Radius, Ter or Max Zones, Date Purch, Current Value.
Driver 1 thru 5:
Name DOB LicNo YrsComExperience DateHired 3YrsTickets or Accidents Phys Impairments
Driver 6 thru 10:
Name DOB LicNo YrsComExperience DateHired 3YrsTickets or Accidents Phys Impairments
