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Basic Information

What state is your company located in?*

Thank You!

Thank you for considering us for your Trucking Insurance needs. However, we regret to inform you that we are unable to assist you at this time.

Company Name*

DBA Name

Enter your DBA, if applicable

Company Contact for Insurance First Name*

Company Contact for Insurance Last Name*

Email*

Business Phone*

Mobile

Can we text you?*

Yes

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USDOT #*

MC #

FEIN #

Entity Type*

Year Company Opened

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address*

Same as physical address

Street Address Address Line 2 City State ZIP Code

Do you require Terminal coverage?*

Only needed if a specified terminal address needs to be added to the policy. This is a location where cargo is parked or stored overnight on a regular basis. Yes

Yes

Terminal Address

Only needed if a specified terminal address needs to be added to the policy. This is a location where cargo is parked or stored overnight on a regular basis.

Same as physical address

Street Address Address Line 2 City State ZIP Code

Owner First Name*

Owner Last Name*

Owner SS #

Owner DOB*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Is Owner a Driver*

Owner's Drivers License #*

Owner DL State*

Is this a CDL License?*

Owner Years of CDL Experience*

Owner Home Address*

Same as business physical address

Street Address Address Line 2 City State ZIP Code

Coverage Date*

List the date that your current insurance is set to expire or the date that you would like to start the new coverage PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Current Insurance Company

Current Insurance Premium Total

List your current annual insurance or renewal premium total

Auto Liability Limit

Other (Auto Liability)

Cargo Limit

Other (Cargo Limit)

Do you employ mechanics?*

Yes

# of Mechanics*

Annual mechanic payroll*

Any warehouse workers?*

Yes

# of warehouse workers*

Annual warehouse labor payroll*

Any dispatch workers?*

Yes

# of dispatch workers*

Annual dispatch payroll*

General Liability Limits*

Do you need Excess / Umbrella Liability?*

Excess / Umbrella Liability Limits Other Amount Needed ($)*

Optional Endorsements/specialty coverage

Uninsured/Under Insured Motorist

Personal Injury Protection (PIP)

Reefer Breakdown

Trailer Interchange

Non Owned Trailer Physical Damage

Blanket Additional Insured Endorsement

Blanket Waiver of Subrogation Endorsement

Hired & Non-Owned auto coverage

Non-Trucking Liability / Bobtail

Other- Please specify

Optional Endorsements / Specialty Coverage Cont.

Intermodal Carrier Endorsement (UIAA)

Other Coverage Needed*

Non Owned Trailer Phys Dam Amount*

Trailer Interchange Amount*

Vehicle(s) and Trailer(s)

This form allows you to enter up to 6 vehicles and 6 trailers. If you have more than 6 vehicles or trailers, we will reach out to you to gather the remaining information.

Vehicle 1

1. VIN*

1. Vehicle Type*

1. Year*

1. Make*

1. Model*

1. Radius of Travel*

Farthest one way distance vehicle typically travels.

1. Stated Value*

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 2nd Vehicle?

Yes

Vehicle 2

2. VIN*

2. Vehicle Type*

2. Year*

2. Make*

2. Model*

2. Radius of Travel*

Farthest one way distance vehicle typically travels.

2. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 3rd Vehicle?

Yes

Vehicle 3

3. VIN*

3. Vehicle Type*

3. Year*

3. Make*

3. Model*

3. Radius of Travel*

Farthest one way distance vehicle typically travels.

3. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 4th Vehicle?

Yes

Vehicle 4

4. VIN*

4. Vehicle Type*

4. Year*

4. Make*

4. Model*

4. Radius of Travel*

Farthest one way distance vehicle typically travels.

4. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 5th Vehicle?

Yes

Vehicle 5

5. VIN*

5. Vehicle Type*

5. Year*

5. Make*

5. Model*

5. Radius of Travel*

Farthest one way distance vehicle typically travels.

5. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 6th Vehicle?

Yes

Vehicle 6

6. VIN*

6. Vehicle Type*

6. Year*

6. Make*

6. Model*

6. Radius of Travel*

Farthest one way distance vehicle typically travels.

6. Stated Value*

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Trailer(s) Information

Do you have any trailers you want to insure?*

Yes

Trailer 1

T1. VIN*

T1. Trailer Type*

T1. Trailer Description*

T1. Year*

T1. Make*

T1. Model*

T1. Radius of Travel*

Farthest one way distance vehicle typically travels.

T1. Stated Value*

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 2nd Trailer?

Yes

Trailer 2

T2. VIN*

T2. Trailer Type*

T2. Trailer Description*

T2. Year*

T2. Make*

T2. Model*

T2. Radius of Travel*

Farthest one way distance vehicle typically travels.

T2. Stated Value*

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 3rd Trailer?

Yes

Trailer 3

T3. VIN*

T3. Trailer Type*

T3. Trailer Description*

T3. Year*

T3. Make*

T3. Model*

T3. Radius of Travel*

Farthest one way distance vehicle typically travels.

T3. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 4th Trailer?

Yes

Trailer 4

T4. VIN*

T4. Trailer Type*

T4. Trailer Description*

T4. Year*

T4. Make*

T4. Model*

T4. Radius of Travel*

Farthest one way distance vehicle typically travels.

T4. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 5th Trailer?

Yes

Trailer 5

T5. VIN*

T5. Trailer Type*

T5. Trailer Description*

T5. Year*

T5. Make*

T5. Model*

T5. Radius of Travel*

Farthest one way distance vehicle typically travels.

T5. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Add 6th Trailer?

Yes

Trailer 6

T6. VIN*

T6. Trailer Type*

T6. Trailer Description*

T6. Year*

T6. Make*

T6. Model*

T6. Radius of Travel*

Farthest one way distance vehicle typically travels.

T6. Stated Value

Only list a "Stated Value" for units that you want physical damage (comp & collision) coverage for.

Driver(s)

This form allows you to enter up to 10 additional drivers, not including the primary contact and/or secondary contact entered earlier. If your business has more than 10 drivers, we will reach out to you to get the information for the remaining drivers.

Do you have additional drivers?

Yes

Driver 1

Driver 1: Name*

First Last

Driver 1: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 1: Drivers License #*

Driver 1: Drivers License State*

Driver 1: Years Experience*

Driver 1: Have CDL?*

Yes

Driver 1: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 1: # of Accidents (past 3 years)

Driver 1: # of tickets (past 3 years)

Add 2nd Driver

Yes

Driver 2

Driver 2: Name*

First Last

Driver 2: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 2: Drivers License #*

Driver 2: Drivers License State*

Driver 2: Years Experience*

Driver 2: Have CDL?*

Yes

Driver 2: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 2: # of Accidents (past 3 years)

Driver 2: # of tickets (past 3 years)

Add 3rd Driver

Yes

Driver 3

Driver 3: Name*

First Last

Driver 3: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 3: Drivers License #*

Driver 3: Drivers License State*

Driver 3: Years Experience*

Driver 3: Have CDL?*

Yes

Driver 3: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 3: # of tickets (past 3 years)

Driver 3: # of Accidents (past 3 years)

Add 4th Driver

Yes

Driver 4

Driver 4: Name*

First Last

Driver 4: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 4: Drivers License #*

Driver 4: Drivers License State*

Driver 4: Years Experience*

Driver 4: Have CDL?*

Yes

Driver 4: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 4: # of Accidents (past 3 years)

Driver 4: # of tickets (past 3 years)

Add 5th Driver

Yes

Driver 5

Driver 5: Name*

First Last

Driver 5: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 5: Drivers License #*

Driver 5: Drivers License State*

Driver 5: Years Experience*

Driver 5: Have CDL?*

Yes

Driver 5: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 5: # of tickets (past 3 years)

Driver 5: # of Accidents (past 3 years)

Add 6th Driver

Yes

Driver 6

Driver 6: Name*

First Last

Driver 6: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 6: Drivers License #*

Driver 6: Drivers License State*

Driver 6: Years Experience*

Driver 6: Have CDL?*

Yes

Driver 6: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 6: # of Accidents (past 3 years)

Driver 6: # of tickets (past 3 years)

Add 7th Driver

Yes

Driver 7

Driver 7: Name*

First Last

Driver 7: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 7: Drivers License #*

Driver 7: Drivers License State*

Driver 7: Years Experience*

Driver 7: Have CDL?*

Yes

Driver 7: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 7: # of tickets (past 3 years)

Driver 7: # of Accidents (past 3 years)

Add 8th Driver

Yes

Driver 8

Driver 8: Name*

First Last

Driver 8: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 8: Drivers License #*

Driver 8: Drivers License State*

Driver 8: Years Experience*

Driver 8: Have CDL?*

Yes

Driver 8: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 8: # of Accidents (past 3 years)

Driver 8: # of tickets (past 3 years)

Add 9th Driver

Yes

Driver 9

Driver 9: Name*

First Last

Driver 9: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 9: Drivers License #*

Driver 9: Drivers License State*

Driver 9: Years Experience*

Driver 9: Have CDL?*

Yes

Driver 9: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 9: # of tickets (past 3 years)

Driver 9: # of Accidents (past 3 years)

Add 10th Driver

Yes

Driver 10

Driver 10: Name*

First Last

Driver 10: Date of Birth*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 10: Drivers License #*

Driver 10: Drivers License State*

Driver 10: Years Experience*

Driver 10: Have CDL?*

Yes

Driver 10: Hire Date*

PLEASE USE THE FOLLOWING FORMAT MM/DD/YYYY

Driver 10: # of Accidents (past 3 years)

Driver 10: # of tickets (past 3 years)

Commodities

What type(s) of commodities do you haul? The grand total of all commodities should equal 100%.

Commodity 1*

Commodity 1 Percent*

Add Commodity 2

Add Another Commodity

Commodity 2*

Commodity 2 Percent*

Add Commodity 3

Add Another Commodity

Commodity 3*

Commodity 3 Percent*

Add Commodity 4

Add Another Commodity

Commodity 4*

Commodity 4 Percent*

Add Commodity 5

Add Another Commodity

Commodity 5*

Commodity 5 Percent*

Add Commodity 6

Add Another Commodity

Commodity 6*

Commodity 6 Percent*

Add Commodity 7

Add Another Commodity

Commodity 7*

Commodity 7 Percent*

Add Commodity 8

Add Another Commodity

Commodity 8*

Commodity 8 Percent*

Add Commodity 9

Add Another Commodity

Commodity 9*

Commodity 9 Percent*

Add Commodity 10

Add Another Commodity

Commodity 10*

Commodity 10 Percent*

Other Commodities Needed?

Other Commodities Not Listed Above

Other Commodity Percent*

Total Commodity Percent

This should equal 100%

Please list the upcoming year estimate and prior 4 years of historical gross sales, total mileage, & unit count below. Estimates are acceptable.

Upcoming Year

Upcoming Year Estimated Gross Sales

Upcoming Year Estimated Annual Mileage (all units)

Upcoming Year Number of Trucks

Prior Year

Prior Year Estimated Gross Sales

Prior Year Estimated Annual Mileage (all units)

Prior Year Number of Trucks

2 Years Ago

2. Year

2. Estimated Gross Sales

2. Estimated Annual Mileage (all units)

2. Number of Trucks

3 Years Ago

3. Year

3. Estimated Gross Sales

3. Estimated Annual Mileage (all units)

3. Number of Trucks

4 Years Ago

4. Year

4. Estimated Gross Sales

4. Estimated Annual Mileage (all units)

4. Number of Trucks

Additional Insured(s) and Prior Claims

Have you had any claims in the past 3 years?

Yes

Claim 1: Year

Claim 1: Company Name

Claim 1: Loss Details

Claim 1: Amount

Claim 2: Year

Claim 2: Company Name

Claim 2: Loss Details

Claim 2: Amount

Claim 3: Year

Claim 3: Company Name

Claim 3: Loss Details

Claim 3: Amount

Loss Run Copies- Last 5 years

Attach any loss runs you have already obtained. This will speed up the quoting process. Most insurance companies will require copies to verify the claims history.

Drop files here or

Accepted file types: pdf, png, jpg, Max. file size: 2 MB.

MVRs

If you have current mvrs on your drivers please upload a copy. This will help us verify that pricing is as accurate as possible when the initial quotes are presented.

Drop files here or

Accepted file types: pdf, png, jpg, Max. file size: 2 MB.

IFTA Reports

For Interstate carriers who file quarterly IFTA reports: Please upload the last 4 quarters of full IFTA reports. Carriers will use these to verify your radius and states entered for quoting.

Drop files here or

Accepted file types: pdf, png, jpg, Max. file size: 2 MB.

Consent*

By submitting this applications, I acknowledge that I am authorized to request quotes and provide the information submitted. I am applying for insurance coverage with multiple insurance carriers. I am giving The Haring Agency permission to submit applications and request loss runs on our behalf and to contact me regarding this application, quotes, and for marketing purposes pertaining to our commercial insurance.

I agree

Consent

By submitting this application, I am giving The Haring Agency permission to text, call, and email me for quoting, marketing, and service of insurance.

I agree

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AgencyID

This field is hidden when viewing the form

Online Application From Website

Authorized Signature*

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

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Basic Information

Thank You!

Vehicle(s) and Trailer(s)

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Trailer(s) Information

Trailer 1

Trailer 2

Trailer 3

Trailer 4

Trailer 5

Trailer 6

Driver(s)

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Driver 7

Driver 8

Driver 9

Driver 10

Commodities

Please list the upcoming year estimate and prior 4 years of historical gross sales, total mileage, & unit count below. Estimates are acceptable.

Upcoming Year

Prior Year

2 Years Ago

3 Years Ago

4 Years Ago

Additional Insured(s) and Prior Claims

USA Truck Insurance

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