"*" indicates required fields Business Name* Insured Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is garaging address different from mailing address?* No Yes Garaging Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Type of Business*ex. LLC, sole proprietor, Inc, etc. Type of Trucker*ex. General Freight, car hauler, livestock carrier, etc. FEIN- Federal Employer Identification Number*(This field is protected with bank/military grade encryption.) SSN - Social Security Number*(This field is protected with bank/military grade encryption.) Are you currently insured?*(This question applies to both personal and commercial auto coverage.) No Yes (additional fields will appear) Current Insurance Carrier* Policy Expiration Date* Have you had continuous insurance for at least 1 year?* No Yes Current Bodily Injury Limit?* Do you currently have a General Liability or Business Owner's Policy?*Please select as applicable. General Liability Business Owner's Policy None Insured's Date of Birth* Insured's Driver's License Number and State Issued* Accidents/Violations (Last 5 Years)*Please describe or state none.Truck InformationYear, Make & Model* VIN* Value of Truck*(excluding the value of any permanently attached equipment) Local or Long Distance - How many miles driven one way?* Truck loaned or leased?* Loss Payee*(If yes, please provide address for lienholder.) No Yes Address of Lienholder* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any permanently attached equipment?* No Yes (provide value below) Value of Permantly Attached Equipment* DOT Number (if applicable) Any state or federal filings required?* No Yes What kind of state or federal filings?* Is Electronic Logging Device required to record hours of service?* No Yes What type of items are you hauling?* Does the vehicle require a hazardous material placard?*(This is a label that warns people the truck is transporting hazardous materials.) No Yes Additional Insured to be listed?*An additional insured is a company or individual who is listed by name on the policy, shares many of the rights of the named insured, and who may be liable for an accident that involves an insured person or vehicle. The specific company or individual listed on the policy will receive a copy of any notices (including non-pay cancel invoices) that are issued to the named insured. No Yes Additional Insured*Please list Additional Insured. Waiver of Subrogation needed?*(This eliminates Progressive's ability to recover losses from a 3rd party.) No Yes Hired Auto Liability?*(Hired Auto provides liability coverage for hired (rented, leased, or borrowed) vehicles used for the customer's business.) No Yes Employer Non-Owned Auto Liability?* No Yes Trailer Interchange Coverage needed?*(Covers physical damage to any non-owned trailer while in the customer's care, custody, or control under a lease agreement.) No Yes Motor Truck Coverage needed?*(Pays when the customer is responsible for damage to or loss of the cargo, he or she is transporting due to fire, collision or even hitting or running over the cargo being transported.) No Yes CommentsThis field is for validation purposes and should be left unchanged.
