Commercial Trucking Insurance Application

1

Policy & General Information

Policy Renewal / Start Date *

USDOT Number

Business Structure *

Year Business Started

Years in Trucking Industry

Years Under Current Ownership

PHMSA Registration Number

Website Address

Range of Transport

Interstate Intrastate Both

Does the applicant have any subsidiary or sister companies?

Yes No

If yes, does applicant interchange equipment with them?

Yes No

Name of all subsidiary or sister companies

2

Business Information

Name of Business *

Physical / Garaging Address *

City

State

ZIP Code

Business Phone

Business Email

Business EIN

Mailing Address (if different from above)

Mailing City

Mailing State / ZIP

Additional Named Insureds

List any additional named insureds, related entities, or operations to be included on the policy.

3

Business Owner Information

Owner Full Name *

Date of Birth *

Owner Address *

Primary Phone

Driver License Number *

4

Operations

Both Operation Type % and Commodity % must total 100% each. Include UN numbers for any placarded hazmat commodities.

Operation Type — % Breakdown (must total 100%)

Auto Hauling %

Dry Bulk %

Dry Van (Truckload) %

Dry Van (LTL) %

Flatbed %

Refrigerated %

Intermodal %

Specialized / Overweight %

Tanker (Fuel, Oil, Petroleum) %

Grain Hauling %

Other Operation Type — Description & %

Commodities Transported — % Breakdown (must total 100%)

List each commodity and its percentage of loads. For hazmat, include UN numbers.

Cities / Regions Regularly Traveled Into or Through

Mileage Radius — % of Tractor Miles by Band (must total 100%)

0–75 Miles %

75–150 Miles %

150–300 Miles %

300–500 Miles %

Over 500 Miles — Zone 1 % (AK,CT,DE,DC,FL,LA,ME,MD,MA,MS,NH,NJ,NY,RI,VT,WV,CA counties)

Over 500 Miles — Zone 2 % (AL,AR,AZ,GA,IL,IN,MI,MO,OH,PA,TX,VA,WA)

Over 500 Miles — Zone 3 % (CO,KY,MN,NV,NC,OK,OR,SC,TN,WI)

Over 500 Miles — Zone 4 % (ID,IA,KS,MT,NE,NM,ND,SD,UT,WY)

5

Vehicles & Trailers

1 vehicle

Complete one block per vehicle. Each vehicle includes its own trailer section.

6

Equipment Count by Class

Indicate the number of vehicles operated for each vehicle class across policy years. Leave blank if not applicable.

Vehicle Class	Projected	Current Year	1st Prior	2nd Prior	3rd Prior	4th Prior

7

Driver Information

1 driver

Number of Company Drivers

Number of Owner/Operators

Number of Sub-Contractors

Do you use PSP (Pre-Employment Screening Program)?

Yes No

Minimum Driver Age

Maximum Driver Age

Do you check driving records (MVR) prior to hiring?

Yes No

Do all drivers meet DOT requirements and are driver files maintained?

Yes No

8

Safety & Operations Questions

Safety Management

Do you have a safety manager?

Yes No

Is the safety manager position full-time?

Yes No

Safety Manager Name

Safety Manager Title

% of Time Devoted to Safety

Years of Safety Management Experience

Safety Technology — % of Fleet Equipped

Adaptive Cruise Control %

Lane Change / Departure System %

Speed Governors %

On-Board Video Monitoring %

Telematics %

Other Active Safety Controls %

Describe telematics / other safety systems used

Operations Questions

9

Hazardous Materials

10

Mileage & Revenue History

	Projected	Current Year	1st Prior	2nd Prior	3rd Prior	4th Prior
Revenue Units
Gross Receipts ($)
Total Mileage

11

Loss History & Prior Coverage

Prior Insurance — Liability (Current + 2 Prior Years)

Prior Insurance — Physical Damage (Current + 2 Prior Years)

Prior Insurance — Cargo (Current + 2 Prior Years)

12

General Liability & Facilities

Terminals, Drop Yards, Warehouses & Other Facilities

List each facility location. Non-trucking payroll is required for GL coverage to be offered.

13

Coverages Requested

Auto Liability

Combined Single Limit (CSL) per Accident

Auto Liability Deductible

Excess or Umbrella Limits Needed?

Yes No

If yes, additional limit needed

Desired Auto Symbol(s)

Symbol 67 – Specifically Described Symbol 68 – Hired Auto Only Symbol 71 – Non-Owned Only

If hired auto — Annual estimated cost of hire ($)

If non-owned coverage — Number of employees

Non-Trucking / Bobtail Liability — Leased to

Uninsured / Underinsured Motorist & PIP

UM Limit

UIM Limit

Medical Payments Limit

PIP Limit

UM/UIM Garage State

PIP Garage State

Auto Physical Damage (Collision & Comprehensive)

Physical Damage Deductible

Combined / Single Physical Damage Deductible?

Yes No

Trailer Interchange — Maximum Trailer Value ($)

% of Loads Using Non-Owned Trailer (100% if no trailers owned)

Average Value of Non-Owned Trailers Used ($)

Towing, Wrecker & Storage Limit

Motor Truck Cargo

Cargo Limit Desired per Vehicle ($)

Cargo Deductible

Refrigeration Breakdown Coverage Needed?

Yes No

Average Commodity Value per Load ($)

Maximum Commodity Value per Load ($)

Truckers General Liability

Hired Auto Liability

General Liability Needed?

Yes No

GL General Aggregate Limit

Total Number of Employees (for Employers Non-Ownership)

Basket Deductible (11–25 Power Units Only)

Additional Coverages Needed

Rental Reimbursement Rental with Downtime Roadside Assistance Gap Coverage Employer Non-Owner Auto Liability Non-Owned Trailer Physical Damage

🔒 Garage Keepers — Locations Up to 3 locations

Covers customer vehicles in your care, custody, or control.

14

Filings & Compliance

State or Federal Filings Required?

Yes No

Includes Federal Filings, MCS-90, and State Filings.

Filing Types Needed

Federal Liability MCS-90 State Filing

State Filing — State & Type

ELD (Electronic Logging Device) Required?

Yes No

Any special hazmat filings required?

Yes No

If yes, provide specifics

15

Additional Insureds & Waivers of Subrogation

Number of Named Additional Insureds

Number of Named Waivers of Subrogation

Blanket Additional Insured Endorsement Needed by Contract?

Yes No

Blanket Waiver of Subrogation Endorsement Needed?

Yes No

16

Existing Insurance

Are You a Current Progressive Customer?

Yes No

Other Business Coverages Currently Carried

General Liability Business Owner Policy (BOP) None

Do you agree to promptly report all driver changes and claims to your agent?

Yes No

Is all equipment operated under applicant's authority scheduled on the application?

Yes No

Application Received!