Insurance Forms - Truckers Insurance

Business Information
Company Name		Phone
Street Address		City
State	New York Pennsylvania Maryland	Zip Code
Contact Person		Email

Driver Information
	Driver #1	Driver #2	Driver #3
Gender	Male     Female	Male     Female	Male     Female
Birth Date(00/00/0000)
Marital Status	Unmarried Married	Unmarried Married	Unmarried Married
Driver License Number
License State	New York Pennsylvania Maryland Other	New York Pennsylvania Maryland Other	New York Pennsylvania Maryland Other
Social Security Number
Have you had continuous liability insurance for the past 6 months with no more than a 30 day lapse?		Yes   No

Additional Information
Number of Years In Business
Types of Cargo Hauled (describe fully)
Type of Motor Carrier: (a) Hauls own merchandise exclusively: Yes  No (b) Public Truckman (If both, show percentage of each): Common Carrier-Percentage  Contract Carrier-Percentage
List Cities Where Cargo Is Hauled
Is Filing To Be Made With The ICC	Yes  No
List of States Which Filings Are To Be Made
Present Insurance Company
Has any carrier cancelled or refused to issue or renew a policy?	Yes  No
If Yes, list Company and why?

Terminal Exposure
Primary Address of Terminal (Street Address, City, State, Zip Code)
Fire and Theft Precautions At Terminal

Schedule of Equipment
	Manufacturer	Model	Year	VIN Number	Limit of Cargo Liability
#1
#2
#3
#4
#5
(a)	Which are equipped with automatic alarms?
(b)	Do vehicles carry fire extinguishers?			Yes  No
(c)	What percentage of hauling is done at night?			%
(d)	List principal shippers:

Type Insurance Desired
Standard Policy: fire, wind, collision, upset, collapse, flood	Yes   No
Broad Policy: same perils as standard, plus theft of entire package	Yes   No
Deductible Amount Desired	$
Do you currently have other insurance policies/coverage with Skyline Insurance: Yes   No

Additional Comments
Insert Questions, Comments And/Or Additional Information Here:

DECLARATION & DISCLOSURE
This application shall not be binding on the Underwriters unless and until a contract of insurance is issued and delivered in accordance herewith and then only as the commencement date of said insurance and in accordance with all terms thereof. The Applicant hereby covenants and agrees to and with the Underwriters that the foregoing statements and answers fully and truly represent, to the best of the Applicant's knowledge, all the facts and circumstances with regard to the risk to be insured. The Applicant also agrees that the answers and statements contained herein form the basis and conditions of the insurance.

The Applicant understands that the application can't be signed.