"*" indicates required fields

1Basic Info

2Contact(s)

3Trucks & Trailers

4Drivers

5Commodities

6AIs & Claims

7Wrapping Up

Basic Information

Is your business currently insured?*

Yes

Insurance Carrier Name*

Current policy expiration date*

Month

Day

Year

How many years of insurance under the same business name?*

Why are you looking to replace your current policy?

Is this a New Venture or was there a Lapse in Coverage?*

New Venture

Lapse in Coverage

When and Why did the lapse in coverage occur?

Desired Coverages*

(Select all that apply)

Auto Liability

Physical Damage

Cargo

General Liability

Bobtail

Non-Trucking Liability

Umbrella

Commercial Property

Occupational Accident

Workers Comp

Hired Non-Owned Auto

What Effective Date do you want the policy to be?*

Month

Day

Year

How is the business structured?*

Sole-Proprietor

Partnership

LLC

Corporation

Other

What is the Legal Name of the Business?*

DBA

DOT#

MC#

EIN / TNN

Website

Business Mailing Address*

Street Address Address Line 2 City State ZIP Code

Business Garaging Address

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Are all vehicles garaged at the same location?*

Yes

Year Business Established*

Describe Operations

Do you haul any oversized or overweight cargo?*

Yes

Primary Contact

Name*

First Last

Date of Birth*

Month

Day

Year

Phone*

Mobile Phone

Can we text you?

Yes

Email*

Designated Financial Responsibility for Company?*

Yes

What is your Role?*

Owner / Operator

Management

Other

Owner / Operator - Both a Manager and included on the policy as a Driver.
Manager - Strictly a manager, is NOT a Driver on the policy.
Other - Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.

Drivers License Number*

Drivers License State*

CDL Year Originally Issued?*

How many years of Management Experience?*

How many years of Trucking Experience?*

Is there a Secondary business contact?*

Yes

Secondary Contact

Secondary Contact: Name*

First Last

Secondary Contact: Date of Birth*

Month

Day

Year

Secondary Contact: Phone*

Secondary Contact: Email*

Secondary Contact: What is your Role?*

Owner / Operator

Management

Financial Responsibility

Other

Owner / Operator - Both a Manager and included on the policy as a Driver.
Manager - Strictly a manager, is NOT a Driver on the policy.
Other - Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.

Secondary Contact: Drivers License Number*

Secondary Contact: Drivers License State*

Secondary Contact: CDL Year Originally Issued?*

Secondary Contact: How many years of Management Experience?*

Secondary Contact: How many years of Trucking Experience?*

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. GVW

Hidden

1. Body Type

Hidden

1. Series

Hidden

1. # of Wheels

Hidden

1. Wheelbase

1. Radius of Travel*

Farthest one way distance vehicle typically travels.

1. Garaging Zip*

1. Permanently Attached Equipment?

Yes

1. Equipment Value*

1. Need Comprehensive or Collision Coverage?

Yes

1. Vehicle Value*

1. Is there a loan/lease on vehicle?

Yes

1. Loss Payee's Name & Address

Add 2nd Vehicle?

Yes

Vehicle 2

2. VIN*

2. Vehicle Type*

2. Year*

2. Make*

2. Model*

2. GVW

Hidden

2. Body Type

Hidden

2. Series

Hidden

2. # of Wheels

Hidden

2. Wheelbase

2. Radius of Travel*

Farthest one way distance vehicle typically travels.

2. Garaging Zip*

2. Permanently Attached Equipment?

Yes

2. Equipment Value*

2. Need Comprehensive or Collision Coverage?

Yes

2. Vehicle Value*

2. Is there a loan/lease on vehicle?

Yes

2. Loss Payee's Name & Address

Add 3rd Vehicle?

Yes

Vehicle 3

3. VIN*

3. Vehicle Type*

3. Year*

3. Make*

3. Model*

3. GVW

Hidden

3. Body Type

Hidden

3. Series

Hidden

3. # of Wheels

Hidden

3. Wheelbase

3. Radius of Travel*

Farthest one way distance vehicle typically travels.

3. Garaging Zip*

3. Permanently Attached Equipment?

Yes

3. Equipment Value*

3. Need Comprehensive or Collision Coverage?

Yes

3. Vehicle Value*

3. Is there a loan/lease on vehicle?

Yes

3. Loss Payee's Name & Address

Add 4th Vehicle?

Yes

Vehicle 4

4. VIN*

4. Vehicle Type*

4. Year*

4. Make*

4. Model*

4. GVW

Hidden

4. Body Type

Hidden

4. Series

Hidden

4. # of Wheels

Hidden

4. Wheelbase

4. Radius of Travel*

Farthest one way distance vehicle typically travels.

4. Garaging Zip*

4. Permanently Attached Equipment?

Yes

4. Equipment Value*

4. Need Comprehensive or Collision Coverage?

Yes

4. Vehicle Value*

4. Is there a loan/lease on vehicle?

Yes

4. Loss Payee's Name & Address

Add 5th Vehicle?

Yes

Vehicle 5

5. VIN*

5. Vehicle Type*

5. Year*

5. Make*

5. Model*

5. GVW

Hidden

5. Body Type

Hidden

5. Series

Hidden

5. # of Wheels

Hidden

5. Wheelbase

5. Radius of Travel*

Farthest one way distance vehicle typically travels.

5. Garaging Zip*

5. Permanently Attached Equipment?

Yes

5. Equipment Value*

5. Need Comprehensive or Collision Coverage?

Yes

5. Vehicle Value*

5. Is there a loan/lease on vehicle?

Yes

5. Loss Payee's Name & Address

Add 6th Vehicle?

Yes

Vehicle 6

6. VIN*

6. Vehicle Type*

6. Year*

6. Make*

6. Model*

6. GVW

Hidden

6. Body Type

Hidden

6. Series

Hidden

6. # of Wheels

Hidden

6. Wheelbase

6. Radius of Travel*

Farthest one way distance vehicle typically travels.

6. Garaging Zip*

6. Permanently Attached Equipment?

Yes

6. Equipment Value*

6. Need Comprehensive or Collision Coverage?

Yes

6. Vehicle Value*

6. Is there a loan/lease on vehicle?

Yes

6. Loss Payee's Name & Address

Trailer(s) Information

Do you have any trailers you want to insure?*

Yes

Trailer 1

T1. VIN*

T1. Trailer Type*

T1. Year*

T1. Make*

T1. Model*

T1. GVW

T1. Radius of Travel*

Farthest one way distance vehicle typically travels.

T1. Garaging Zip*

T1. Permanently Attached Equipment?

Yes

T1. Equipment Value*

T1. Need Comprehensive or Collision Coverage?

Yes

T1. Trailer Value*

T1. Is there a loan/lease on trailer?

Yes

T1. Loss Payee's Name & Address

Add 2nd Trailer?

Yes

Trailer 2

T2. VIN*

T2. Trailer Type*

T2. Year*

T2. Make*

T2. Model*

T2. GVW

T2. Radius of Travel*

Farthest one way distance vehicle typically travels.

T2. Garaging Zip*

T2. Permanently Attached Equipment?

Yes

T2. Equipment Value*

T2. Need Comprehensive or Collision Coverage?

Yes

T2. Trailer Value*

T2. Is there a loan/lease on trailer?

Yes

T2. Loss Payee's Name & Address

Add 3rd Trailer?

Yes

Trailer 3

T3. VIN*

T3. Trailer Type*

T3. Year*

T3. Make*

T3. Model*

T3. GVW

T3. Radius of Travel*

Farthest one way distance vehicle typically travels.

T3. Garaging Zip*

T3. Permanently Attached Equipment?

Yes

T3. Equipment Value*

T3. Need Comprehensive or Collision Coverage?

Yes

T3. Trailer Value*

T3. Is there a loan/lease on trailer?

Yes

T3. Loss Payee's Name & Address

Add 4th Trailer?

Yes

Trailer 4

T4. VIN*

T4. Trailer Type*

T4. Year*

T4. Make*

T4. Model*

T4. GVW

T4. Radius of Travel*

Farthest one way distance vehicle typically travels.

T4. Garaging Zip*

T4. Permanently Attached Equipment?

Yes

T4. Equipment Value*

T4. Need Comprehensive or Collision Coverage?

Yes

T4. Trailer Value*

T4. Is there a loan/lease on trailer?

Yes

T4. Loss Payee's Name & Address

Add 5th Trailer?

Yes

Trailer 5

T5. VIN*

T5. Trailer Type*

T5. Year*

T5. Make*

T5. Model*

T5. GVW

T5. Radius of Travel*

Farthest one way distance vehicle typically travels.

T5. Garaging Zip*

T5. Permanently Attached Equipment?

Yes

T5. Equipment Value*

T5. Need Comprehensive or Collision Coverage?

Yes

T5. Trailer Value*

T5. Is there a loan/lease on trailer?

Yes

T5. Loss Payee's Name & Address

Add 6th Trailer?

Yes

Trailer 6

T6. VIN*

T6. Trailer Type*

T6. Year*

T6. Make*

T6. Model*

T6. GVW

T6. Radius of Travel*

Farthest one way distance vehicle typically travels.

T6. Garaging Zip*

T6. Permanently Attached Equipment?

Yes

T6. Equipment Value*

T6. Need Comprehensive or Collision Coverage?

Yes

T6. Trailer Value*

T6. Is there a loan/lease on trailer?

Yes

T6. Loss Payee's Name & Address

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*

Month

Day

Year

Driver 1: Drivers License #*

Driver 1: Drivers License State*

Driver 1: Years Experience*

Driver 1: Have CDL?*

Yes

Driver 1: Hire Date*

Driver 1: Relationship

Employee

Leased

Owner / Operator

Driver 1: CDL Year*

Add 2nd Driver

Yes

Driver 2

Driver 2: Name*

First Last

Driver 2: Date of Birth*

Month

Day

Year

Driver 2: Drivers License #*

Driver 2: Drivers License State*

Driver 2: Years Experience*

Driver 2: Have CDL?*

Yes

Driver 2: Hire Date*

Driver 2: Relationship

Employee

Leased

Owner / Operator

Driver 2: CDL Year*

Add 3rd Driver

Yes

Driver 3

Driver 3: Name*

First Last

Driver 3: Date of Birth*

Month

Day

Year

Driver 3: Drivers License #*

Driver 3: Drivers License State*

Driver 3: Years Experience*

Driver 3: Have CDL?*

Yes

Driver 3: Hire Date*

Driver 3: Relationship

Employee

Leased

Owner / Operator

Driver 3: CDL Year*

Add 4th Driver

Yes

Driver 4

Driver 4: Name*

First Last

Driver 4: Date of Birth*

Month

Day

Year

Driver 4: Drivers License #*

Driver 4: Drivers License State*

Driver 4: Years Experience*

Driver 4: Have CDL?*

Yes

Driver 4: Hire Date*

Driver 4: Relationship

Employee

Leased

Owner / Operator

Driver 4: CDL Year*

Add 5th Driver

Yes

Driver 5

Driver 5: Name*

First Last

Driver 5: Date of Birth*

Month

Day

Year

Driver 5: Drivers License #*

Driver 5: Drivers License State*

Driver 5: Years Experience*

Driver 5: Have CDL?*

Yes

Driver 5: Hire Date*

Driver 5: Relationship

Employee

Leased

Owner / Operator

Driver 5: CDL Year*

Add 6th Driver

Yes

Driver 6

Driver 6: Name*

First Last

Driver 6: Date of Birth*

Month

Day

Year

Driver 6: Drivers License #*

Driver 6: Drivers License State*

Driver 6: Years Experience*

Driver 6: Have CDL?*

Yes

Driver 6: Hire Date*

Driver 6: Relationship

Employee

Leased

Owner / Operator

Driver 6: CDL Year*

Add 7th Driver

Yes

Driver 7

Driver 7: Name*

First Last

Driver 7: Date of Birth*

Month

Day

Year

Driver 7: Drivers License #*

Driver 7: Drivers License State*

Driver 7: Years Experience*

Driver 7: Have CDL?*

Yes

Driver 7: Hire Date*

Driver 7: Relationship

Employee

Leased

Owner / Operator

Driver 7: CDL Year*

Add 8th Driver

Yes

Driver 8

Driver 8: Name*

First Last

Driver 8: Date of Birth*

Month

Day

Year

Driver 8: Drivers License #*

Driver 8: Drivers License State*

Driver 8: Years Experience*

Driver 8: Have CDL?*

Yes

Driver 8: Hire Date*

Driver 8: Relationship

Employee

Leased

Owner / Operator

Driver 8: CDL Year*

Add 9th Driver

Yes

Driver 9

Driver 9: Name*

First Last

Driver 9: Date of Birth*

Month

Day

Year

Driver 9: Drivers License #*

Driver 9: Drivers License State*

Driver 9: Years Experience*

Driver 9: Have CDL?*

Yes

Driver 9: Hire Date*

Driver 9: Relationship

Employee

Leased

Owner / Operator

Driver 9: CDL Year*

Add 10th Driver

Yes

Driver 10

Driver 10: Name*

First Last

Driver 10: Date of Birth*

Month

Day

Year

Driver 10: Drivers License #*

Driver 10: Drivers License State*

Driver 10: Years Experience*

Driver 10: Have CDL?*

Yes

Driver 10: Hire Date*

Driver 10: Relationship

Employee

Leased

Owner / Operator

Driver 10: CDL Year*

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*

Total Commodity Percent

This should equal 100%

Current Insurance Premium (all coverage)*

Please provide the current and/or upcoming renewal premium for your current policies.

Other commodities not listed above

If you haul other commodities not listed above, please enter them here.

Additional Insured(s) and Prior Claims

Does anyone need to be listed as Additional Insured

Yes

Additional Insured(s) Information

Additional Insured Files

If your AIs have documents or requirements you may upload those here.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB, Max. files: 10.

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

Would you like a quote from a specific agent?

How were you referred to us?

Additional Comments

Attach File(s)

Drop files here or

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

Comments

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

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Basic Information

Primary Contact

Secondary Contact

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

Additional Insured(s) and Prior Claims

USA Truck Insurance

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