Loss Runs are required (unless a new venture)

Please provide the following:

Name of Business

Mailing Address

Physical Address

President / Owner Full Name (Inc. date of birth)

Inception date of business

FEIN/EIN – TAXPAYER ID

Cell Phone Number

Email address

Drivers

Name

Class type (A, B or C)

Date of Birth

State of Licensure

License Number

State and Federal Filings

DOT Number

MC Number

Radius (200, 300, 500 or unlimited)

Power (Schedule of Autos) Units (MUST provide more than VIN #)

Year

Value

Make

Model

VIN

Cargo Commodities (Type and Percentage)

List the top three commodities by name and percentage

List top three commodities by percentage

Do you need trailer interchange coverage?
Yes

Refrigerated Products coverage?
Yes