Need by Date:
Business Name (If you have the PUCO authority, enter name exactly as filed with PUCO):
*
Contact Name(s):
*
Mailing Address (please separate with commas):
*
Cell, Business, and/or Home Phone:
*
Fax Number:
Email:
Garaging Address (if different than mailing address):
Commodities Hauled:
Normal Radius of Operation:
1-50
51-200
201+
Current Insurance Carrier:
Current Insurance Expiration Date:
Liability Limit of Insurance:
$1,000,000
$500,000
Uninsured Motorist Limit:
$1,000,000
$500,000
$300,000
$25,000
None
Medical Payments
$1,000
$5,000
$10,000
None
Deductibles Physical Damage to Trucks:
$500
$1,000
$2,500
$5,000
Number & Amount of any Claims Paid out by Insurance Carrier in the Last 3 Years:
TRUCK 1
Year, Make, Model:
Serial Number:
Gross Vehicle Weight:
State Value IF Physical Damage Desired:
Average Annual Miles Driven:
TRUCK 2
Year, Make, Model:
Serial Number:
Gross Vehicle Weight:
State Value IF Physical Damage Desired:
Average Annual Miles Driven:
TRUCK 3
Year, Make, Model:
Serial Number:
Gross Vehicle Weight:
State Value IF Physical Damage Desired:
Average Annual Miles Driven:
TRUCK 4
Year, Make, Model:
Serial Number:
Gross Vehicle Weight:
State Value IF Physical Damage Desired:
Average Annual Miles:
TRUCK 5
Year, Make, Model:
Serial Number:
Gross Vehicle Weight:
State Value IF Physical Damage Desired:
Average Annual Miles:
DRIVER 1
Name on License:
State of License:
License Number:
Date of Birth (mm/dd/yyyy):
CDL Type:
Years of Experience:
DRIVER 2
Name on License:
State of License:
License Number:
Date of Birth (mm/dd/yyyy):
CDL Type:
Years of Experience:
DRIVER 3
Name on License:
State of License:
License Number:
CDL Type:
Date of Birth (mm/dd/yyyy):
CDL Type:
Years of Experience: