General Insurance Agency Group 3123

General Insurance Agency Group

Trucking insurance underwriting intake form

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Company Name *

Phone *

Federal Tax ID # *

DBA Name

Email *

How many owners *

Business start date *

Requested policy effective date *

Year first insured *

Owner 1 *

First

Last

Owner 2 *

First

Last

Owner 3 *

First

Last

Owner 4 *

First

Last

Owner 5 *

First

Last

Owner 6 *

First

Last

Contact person *

First

Last

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Is mailing address same as in SAFER ? *

Mailing Address *

Address Line 1

City

State

Zip Code

Is garaging address same as in SAFER ? *

Garaging Address *

Address Line 1

City

State

Zip Code

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DOT # *

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 ? *

Is authority currently active ? *

Commodities hauled *

Authority type *

For hire
Private

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ELD Provider

Do you plan to add more trucks in the next 12 months ?

ELD Account # or Email assigned

How many trucks are you planning to add ?

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Number of Trucks *

Number of Drivers *

Number of Trailers *

Requested Coverage

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Auto Liability coverage amount

Comp. and Collision

Reefer Breakdown

PIP/ Medical coverage amount

General Liability amount

Trailer Interchange

Cargo coverage amount

Deductable amount

Uninsured/ Underinsured

Attachments

Upload 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.

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