New Account Questionnaire


Please complete the following form then click the Submit button at the bottom.
Company Name
   DOT#    MC#
Company Owner Name
Address
City
State
    Zip
Phone #
   Fax #
Email
   Web Site
Tax ID
   Years in Business
Gross Revenue
Last 12 Months     Next 12 Months
Do you have a warehouse and/or loading dock?    Square Feet
# of Trucks    # of Trailers    # of Company Cars
Garage Address
Please provide a copy of your Cargo and Truck Liability Declaration Pages  click here to email this info

VEHICLE LIST
Year    Make
VIN#
GVW
Value
Owned
Leased
  
  
  
  
  
  
Email additional vehicle list if space provided above is not sufficient  click here to email this info

DRIVER LIST
Name
License/State
DOB
Yrs Exp
Owner Op?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Email additional vehicle list if space provided above is not sufficient  click here to email this info
Do you hire drivers younger than 24 or over 65? Yes    No
Please provide any Lien Holder Information in the box below.
Do you require Physical Damage on any of the vehicles? Yes    No

Please specify which ones by providing a value on your vehicle list.

Deductible desired for physical Damage:    $500    $1,000     $2,500    $5,000

Do you do pier work?    Yes     No

Radius of operations in miles:  0–150 %   150–300 %   300–500 %   >500 %   

Commodities Hauled and % of TotalCoverage Limits Required
%Trucking
%Bodily Injury/Property Damage
$
%Uninsured/Under Insured
$
%Trailer Interchange
$
%Cargo
$

PRIOR INSURANCE
Truck Liability Cargo
1. Company 1. Company
Policy # Years Policy # Years
2. Company 2. Company
Policy # Years Policy # Years
3. Company 3. Company
Policy # Years Policy # Years
Please submit at least 3 previous years of loss runs (Not applicable for new venture)  click here to email these reports

Please submit your last 4 quarters of IFTA Reports (Not applicable for new venture)  click here to email these reports

What certificates and filings are needed for your operation?

Total # of Employees Total # of Owner Operators

What coverage do you require? (Please check all that apply)
General Liability
Auto/Truck Liability
Physical damage
Workers Compensation (State )
General Liability
Warehouse Legal Liability
Cargo
Property
Other: 
Please submit any contracts, leases, and/or interchange agreements, etc. or any additional information.
Use box below or click here to email this information.



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