TRUCK INSURANCE IN TEXAS Is this a first time application or renewal? First Time Renewal Lease? Yes No Business Name EIN Email * Phone (###) ### #### Owner Full Name First Name Last Name Owner Date of Birth MM DD YYYY Business Address Address 1 Address 2 City State/Province Zip/Postal Code Country How long has your company been in business? Address where your truck will be parked Address 1 Address 2 City State/Province Zip/Postal Code Country Vehicle 1 Year Make Model GVW Vin Date of Purchase MM DD YYYY Type Hotshot Box Truck Cargo Van Tractor Stated Value Are you insuring more than one vehicle? Yes No If Yes, please provide VIN numbers and value for each truck Is this owned or a long term rental? Owned Long Term Rental Trailer Information Year Make Model GVW VIN Stated Value Is this owned or rental? Owned Rental Driver Information Driver Full Name First Name Last Name Type Owner Owner Operator Employee Driver's DOB MM DD YYYY Years of Experience Drivers License Does driver have a CDL? License State Year Obtained Date Hired MM DD YYYY Coverage Questions Do you need Cargo Coverage? Yes No Do you require General Liability coverage? Yes No Business Type Individual Partnership Corporation LLC Other Do you operate in more than one state? Yes No Do you haul hazardous material? Do you rent your vehicle to others? Insurance Request Do you currently have an auto commercial policy? Yes No Coverage Needed Auto Liability General Liability Cargo Physical Damage Road Assistance Worker Compensation Coverage Limits Needed Auto Liability General Liability Cargo Physical Damage Type of Cargo Dry Goods Refrigerated Goods Do you require federal fillings? Yes No DOT MC Date of Authority MM DD YYYY Is your company Intra or Interstate? Intra Interstate Attachments Thank you!
