TRUCKING
				AUTO LIABILITY &
				PHYSICAL DAMAGE
Insureds Name:
Street Address:
City:
State:		Select Maryland Pennsylvania Delaware New Jersey Virginia Washington DC			Zip:
County:
Description of business:
Is this a New Venture:			Select Yes No
Years in this Business:
Radius of Operation:			Select Less than 50 Miles 50 to 100 Miles 100 to 300 Miles Over 300 Miles
Largest City Entered:
Concerns Insured is hauling for:								Percent
Name					Commodity			of Time
Vehicle Schedule:
							Vehicle ID
Year	Make		Type		GVW		Number
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
			Select Van Truck Dump Truck Tractor Trailer Dump Trailer		Select Light Medium Heavy Extra Heavy
Driver Schedule:
			Date of	Years
Name			Birth	Exp.	Violations
Name			License State		License Number			Hire Date
Liability Limits:			Select 100,000 300,000 500,000 1,000,000
UM / UIM:			Select 100,000 300,000 500,000 1,000,000
PIP / FPB Limits:
Are Filings Needed:			Select No Filings ICC Filing PUC Filing
ICC Docket Number:
PUC Docket Number:
Does Insured want
physical damage:			Select Coverage Wanted No Coverage Wanted
Year	Make		VIN		Stated Value
	Spec. Perils Deductible:			Select 250 500 1,000 2,500
	Comp. Deductible:			Select 250 500 1,000 2,500
	Collision Deductible:			Select 250 500 1,000 2,500
Prior Carrier:
Prior Premium:
Any Claims past 3 Years:				Yes No
If claims, please provide details:
Would you like cargo coverage:				Yes No
If yes, please advise limit of coverage needed:
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact:
Contact E-Mail Address:
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