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Producer Name _______________________________________ Code# _____________ Date: ________________
Telephone# ___________________ Fax# ___________________ Email Address: ___________________________
Applicant Name: ________________________________ Business Name: ___________________________________
Mailing Address: __________________________________ Zip: _______________
Garaging Address: ________________________________ Zip: _______________
Description of commodities hauled: Provide the 4 most common commodities and % of each
% _____ % _____% _____ % _____
Radius: ______________ Will applicant be crossing state lines: YES NO(furthest one way distance in miles) If yes, list states entered: ________________________
Years Trucking Experience: ___________How many years prior insurance under the business name listed above? _________
# of Losses Paid Out
*2 years verifiable experience with commercial class license required Class Lic. Date of Birth Yrs Coml Exper. # Moving Viol # Non-Moving viol Major Viol. # Accidents
CARGOMax value per laod CA# ____________
$750,000 CSL _____ $1,000 _____ $30,000 $ ____________ MC# ____________$1,000,000 CSL _____ $5,000 _____ $60,000 Deductible DOT# ____________
Other:$ _________ $ ____________
Year Make - Model Stated Value Deductible
1234
Year Make - Model Stated Value Deductible
1234
Hired Auto Liability Coverage (select one) Non-owned Auto Liab
Required Trailer Value: ________________ Cost of hire: ___________ # of Employees: ______*Refer to applicants Equipment Provider Checklist to confirm value If Any (Required by contract) If Any (Required by contract)
*If UIIA/UIIE Endorsement Required Please complete the following…
Year Prior
Annual Premium
Physical DamageTRACTOR / POWER UNIT *5+ units require completed app & 3 years loss runsVIN
FILINGS
TRUCKER FOR HIRE - QUOTE REQUEST
PRIOR INSURANCE INFORMATION -- *4 years prior continuous coverage can qualify for considerable discounts.
Commercial Department
City: _____________________
MVR ACTIVITY LAST 36 MONTHS
Tel # 714-738-1383 ---- Fax # 714-921-1160
Year Prior
Current
Year Prior
Will applicant be hauling under authority of other trucking firm? If yes, provide MC#: ___________
Name
Company Name
Medical UM Limit: LIABILITY LIMITS
Eff dates (month/year)
Body Type
TRAILER
DRIVERS SCHEDULE - If no MVR attached, the MVR activity must section must be complete for indication premium only
Liability: _____ _____
City: _____________________
Trailer Interchange Agreement
Physical Damage
*Turnaround time is 24-48 hours from time received if above information is FULLY COMPLETED. DOWNLOAD APPLICATIONS AND FORMS AT www.RMISMGA.com
VIN
PLEASE EMAIL TO: [email protected]
Body Type
YesNo
