"*" indicates required fields

1Basic Info

2Contact(s)

3Trucks & Trailers

4Drivers

5Commodities

6Additional Insureds

7Wrapping Up

Basic Information

Is your business currently insured?*

Yes

Insurance Carrier Name*

How many years of insurance under the same business name?*

Current policy expiration date*

Month

Day

Year

Why are you looking to replace your current policy?

Is this a New Venture or was there a Lapse in Coverage?*

New Venture

Lapse in Coverage

When and Why did the lapse in coverage occur?

Desired Coverages*

(Select all that apply)

Auto Liability

Physical Damage

Cargo

General Liability

Bobtail

Non-Trucking Liability

Umbrella / Excess

Commercial Property

Occupational Accident

Workers Comp

Hired/Non-Owned Auto

What Effective Date do you want the policy to be?*

MM slash DD slash YYYY

Do you have a DOT#?*

Yes

Pending

DOT#*

Do you have an MC#?*

Yes

Pending

MC#*

Do you have a Tax ID Number?*

Yes

Pending

EIN / TNN*

How is the business structured?*

Sole-Proprietor

Partnership

LLC

Corporation

Other

What is the Name of the Business?*

Has the business either Currently or Previously operated under a DBA?

Yes

DBA*

Website

Business Mailing Address*

Street Address Address Line 2 City State ZIP Code

Business Garaging Address

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Are all vehicles garaged at the same location?*

Yes

Year Business Established*

Primary Contact

Name*

First Last

Date of Birth*

Month

Day

Year

Phone*

Mobile Phone

Can we text you?*

Yes

Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel. Privacy Policy.

Email*

Designated Financial Responsibility for Company?*

Yes

What is your Role?*

Owner / Operator

Management

Other

Owner / Operator - Both a Manager and included on the policy as a Driver.
Manager - Strictly a manager, is NOT a Driver on the policy.
Other - Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.

Drivers License Number*

Drivers License State*

CDL Year Originally Issued?*

How many years of Management Experience?*

How many years of Trucking Experience?*

Is there a Secondary business contact?*

Yes

Secondary Contact

Secondary Contact: Name*

First Last

Secondary Contact: Date of Birth*

Month

Day

Year

Secondary Contact: Phone*

Secondary Contact: Email*

Secondary Contact: What is your Role?*

Owner / Operator

Management

Financial Responsibility

Other

Owner / Operator - Both a Manager and included on the policy as a Driver.
Manager - Strictly a manager, is NOT a Driver on the policy.
Other - Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.

Secondary Contact: Drivers License Number*

Secondary Contact: Drivers License State*

Secondary Contact: CDL Year Originally Issued?*

Secondary Contact: How many years of Management Experience?*

Secondary Contact: How many years of Trucking Experience?*

Truck(s) Information

Trucks List

VIN	Year	Make	Model	Actions

There are no Trucks.

Maximum number of trucks reached.

Do you have any trailers you want to insure?*

Yes

Trailer(s) Information

Trailers List

VIN	Year	Make	Model	Actions

There are no Trailers.

Maximum number of trailers reached.

Driver(s)

Do you have additional drivers?

Yes

Drivers List

Driver Name	Date of Birth	Drivers License #	Drivers License State	Actions

There are no Drivers.

Maximum number of drivers reached.

Commodities

What type(s) of commodities do you haul? The grand total of all commodities should equal 100%.

Commodity 1*

Commodity 1 Percent*

Add Commodity 2

Add Another Commodity

Commodity 2*

Commodity 2 Percent*

Add Commodity 3

Add Another Commodity

Commodity 3*

Commodity 3 Percent*

Add Commodity 4

Add Another Commodity

Commodity 4*

Commodity 4 Percent*

Add Commodity 5

Add Another Commodity

Commodity 5*

Commodity 5 Percent*

Add Commodity 6

Add Another Commodity

Commodity 6*

Commodity 6 Percent*

Add Commodity 7

Add Another Commodity

Commodity 7*

Commodity 7 Percent*

Add Commodity 8

Add Another Commodity

Commodity 8*

Commodity 8 Percent*

Add Commodity 9

Add Another Commodity

Commodity 9*

Commodity 9 Percent*

Add Commodity 10

Add Another Commodity

Commodity 10*

Commodity 10 Percent*

Total Commodity Percent

This should equal 100%

Other commodities not listed above

If you haul other commodities not listed above, please enter them here.

Additional Insured(s)

Does anyone need to be listed as Additional Insured

Yes

Additional Insured(s) Information

Additional Insured Files

If your AIs have documents or requirements you may upload those here.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB, Max. files: 10.

Would you like a quote from a specific agent?

How were you referred to us?

Additional Comments

Attach File(s)

Drop files here or

Accepted file types: pdf, png, jpg, Max. file size: 2 MB.

Phone

This field is for validation purposes and should be left unchanged.

MJ Martinez Insurance Agency

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