Retired Trucking Insurance Application

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Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Effective Date

MC #

DOT #

FEIN

List Three Largest Cities of Operation

Number of Years Operating Under Your Own MC# / DOT#

Radius of Operations

0 - 100 Miles 101 - 300 Miles 301 - 500 Miles Over 500 Miles

(please advise of the percentage)

Average Length of Haul (in miles)

Maximum Length of Haul (in miles)

Any Hazmat

Yes No

If Yes, Please Explain

Please attach the last 4 quarters of IFTA reports and loss runs for the past 3 years

No File Chosen

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Commodities

% of Loads (Must Total 100%)

Average Value

Max Value

Wet Steel Coverage Reefer Breakdown

Driver(s) & Owner(s)

Vehicle Schedule

It's ok to contact me via text messaging