Today's Date: Submit
Commercial Truck Insurance Request Name of Applicant DBA# Owner Name Tax ID#
Policy Effective Date Phone # Email MC# / DOT# / CA# U.I.I.A filing City
Mo / Yr business started
Mailing address
State
Zip
City
State
Zip
COMMODITIES – Please identify the commodities transported and percentages below 1. Commodity Percentage 2. Commodity Percentage
3. Commodity
Percentage
6. Commodity
Percentage
Garaging address
4. Commodity
Percentage
5. Commodity
SCHEUDLE OF AUTOS Year Make
Type
LIMITS OF INSURANCE Auto Liability Hired / Non-Owned Yes General Liability Motor Truck Cargo Physical Damage Unidentified Trailer Trailer Interchange
DRIVER INFORMATION Owner’s Name Driver’s Name
Percentage
VIN#
GVW
RADIUS (miles) 0-100: 101-300: 301-500: 501-750: 750+ 48 States Annual Millage
No
Stated Value
CITIES MOST TRAVELED #1 #2 #3 #4 #5 #6 Annual Revenue
Date of Birth
License #
State
Years of Truck Experience
Years w/ Co.
Date of Birth
License #
State
Years of Truck Experience
Years w/ Co.
PRIOR INSURANCE / WORK HISORY From
To
Carrier Name / Prior Insurer
Address (City/State only)
DOT#
Unit Type
Lic Class
Trucksmart Insurance Services, Inc. – Insurance License #0L50537 420 S Grand Avenue, Covina, CA 91724 – Tel: 626-331-0055 – flavia@trucksmartins.com Referred By:
O/L**
VIN#
Intake: