Trucking Insurance Application
Printable Application

Company Name:    MC #:   

Contact Person:   Title:

Phone #:    Fax

Email Address:

Mailing Address

City   State     Zip

Years in Business:     Federal Tax ID #:

Type of Operation:
Reefer
Flatbed
Dry Van
Tankers
Hoppers
Dumps

Number of Units:    Employee     Owner Operator

Cargo:
Commodity Hauled Percentage Maximum Value/Load
1. % $
2. % $
3. % $

HazMat? Yes   No   

Needs Placarding? Yes   No

Over Sized/Over Weight? Yes   No

Major Cities Entered:

Radius of Operation:
800 or More: %
500-800: %
200-500 %
50-200 %
0-50 %

    Average Haul:  miles

    Maximum Haul: miles

Coverage:

Coverage Limits:  Liability $      Deductible $

Cargo Limit $    Deductible $

Renewal Dates:  Liability    Physical Damage:     Cargo:

Current Insurance Agent:     How long? years

Claims Experience:   Current Year:     Prior Years:

Equipment List:
Year Make Value
1. $
2. $
3. $
4. $
5. $
Driver List:
Name Date of Birth Drivers License # Date of Hire
1.
2.
3.
4.
5.

If you have any additional Equipment or Drivers, please email or fax the information to (817) 485-3805  
Attn: Jon Tanner.

Please email or fax the past 2 quarters Fuel Tax Reports or IFTA Mileage Summaries to (817) 485-3805  
Attn: Jon Tanner.

 

We are licensed to write insurance in all 50 states.

© 2006-2007 J.D. Tanner & Associates Insurance Services

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