Get a Quote — Truckin Kings Insurance

1

Applicant & Agency Information

Insured Name *

DOT #

MC #

FEIN #

Effective Date *

Year Established

Business Type

Primary City of Operations

Mailing Address

Street Address

City

State

ZIP

Main Garaging Address

Street Address (or type "Same")

City

State

ZIP

Contact

Contact Name

Phone

Email *

2

Historical Information

Rating Period	Mileage	Revenue	Company Units	Owner/Op Units	PP & Service Units	Total Power Units	# Trailers	# Drivers

3

Operations by Category (must add to 100%)

List each business category and the percentage of operations it represents. All percentages must total 100%.

Category	% of Ops

Destinations (must add to 100%)

City / State	% of Hauls

Commodities Hauled (must add to 100%)

Commodity	% of Hauls

4

Driver Schedule

Full Name	Date of Birth	State Licensed	DL #	Years of Exp	Date of Hire

5

Vehicle Schedule

Year	Make	Type	VIN	Value ($)	APD Ded	Location / Garage

6

Miscellaneous Information

Radius of Operations

0–50 Miles %

51–100 Miles %

101–300 Miles %

301–500 Miles %

501+ Miles %

Max Radius (Miles)

Operations Questions

Driver Hiring Practices (check all that apply)

Safety Devices (check all that apply)

Cameras Accident event recorders (AERs) Geographic driving history data Mileage tracking device Distracted driving warning system Speed warning system Active accident avoidance tech Passive accident avoidance tech No texting/cell phone policy

7

Cargo & General Liability

Cargo

Cargo contractually required Commodities stored overnight Refrigerated units Had a cargo loss

General Liability

GL contractually required Any warehousing Ops at storage lot or impound yard Lease space to others Operations other than trucking Storage of goods/fuels/chemicals Had a GL loss

8

Requested Coverages

Check each coverage you'd like included. Add desired limits or deductibles where applicable. Our team will confirm the best options for your operation.

Coverage	Request?	Desired Limit / Deductible
Auto Liability
Uninsured Motorists – BI/CSL
Uninsured Motorists – PD
Underinsured Motorists – BI
Medical Payments
Personal Injury Protection
Physical Damage – Comprehensive
Physical Damage – Collision
Motor Truck Cargo Liability
Refrigeration Breakdown
General Liability
Non-Trucking / Bobtail Liability
Trailer Interchange
Non-Owned Trailer
On-Hook Liability
Garagekeepers' Liability
Pollution Coverage
Occupational Accident
UIIA Coverage
Excess / Umbrella

Any filings required? (e.g. MCS-90, BMC-91, state filings)

Additional notes or coverage questions

9

Authorization & Signature

By submitting this form, I declare that the statements made in this application are true and correct and agree that any policy issued will be based on the warranties and representations contained herein.

Printed Name *

Title *

Date *

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