General Insurance Agency Group Trucking insurance underwriting intake form Please enable JavaScript in your browser to complete this form.LayoutCompany Name *Phone *Federal Tax ID # *DBA NameEmail *How many owners *Business start date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Requested policy effective date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year first insured *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Owner 1 *FirstLastOwner 2 *FirstLastOwner 3 *FirstLastOwner 4 *FirstLastOwner 5 *FirstLastOwner 6 *FirstLastContact person *FirstLastLayoutIs mailing address same as in SAFER ? *YesNoMailing Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs garaging address same as in SAFER ? *YesNoGaraging Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutDOT # *Radius of operations *Less than 100 mi.100 mi. to 300 mi.300 mi. to 500 mi.500 mi. to 1000 mi.Over 1000 mi.MC #State or other filings required ? *YesNoIs authority currently active ? *YesNoCommodities hauled *Authority type *For hirePrivateLayoutELD ProviderDo you plan to add more trucks in the next 12 months ?YesNoELD Account # or Email assignedHow many trucks are you planning to add ?LayoutNumber of Trucks *Number of Drivers *Number of Trailers *Requested CoverageLayoutAuto Liability coverage amountComp. and Collision YesNoReefer BreakdownYesNoPIP/ Medical coverage amountGeneral Liability amountTrailer InterchangeYesNoCargo coverage amountDeductable amountUninsured/ UnderinsuredYesNoAttachmentsUpload equipment list * Click or drag files to this area to upload. You can upload up to 100 files. Please make sure equipment list contains VIN #, Year, Make, Model, Type i.e. tractor truck, box truck, cargo van or trailer and Value.Upload Drivers Info. * Click or drag files to this area to upload. You can upload up to 100 files. Please upload driver licenses for all drivers.Loss runs for all years up to 5 Click or drag files to this area to upload. You can upload up to 100 files. IFTA for last 4 quarters * Click or drag files to this area to upload. You can upload up to 5 files. Submit