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Official Coalition Member Since 2006
www.ntassoc.com is an Official 2006 Coalition Member

Truck Insurance - Online Free Quote!

DATE:

*APPLICANT:

(Individual Name/Owner)

* EMAIL ADDRESS

* PHONE #:

CELL #:

D/B/A:

GARAGE ADDRESS:

Street:	City:	State:	Zip:

(Where you park your trucks)

*COVERAGE NEEDED:

Primary Coverage	Liability
	Physical Damage
	Cargo
OR
Non-Trucking(Bobtail) and Physical Damage

LIABILITY LIMITS:

Amount:

Other:

MCP/ICC/FHWA Filings:

MC#:
DOT#:
CA#:

OTHER COVERAGES:

Hired Auto:
Non-Owned Trailer:
General Liability:

RADIUS:

(Furthest Destination)

STATES TRAVELED:

CITIES TRAVELED:

CARGO LIMIT:

Amount:	Other:	(Keep in mind that most shippers will require a $100,000 limit)

COMMODITIES:

#1:

#2:

#3:

#4:

Commodities:	%:	Value of Avg. Load:	Max value of Load:




(Example: Lumber	45%	$30,000	$50,000

YEARS IN BUSINESS:

EXPIRATION DATE:

PRIOR CARRIER INFO:

1st Year:

2nd Year:

3rd Year:

Dates:	Insurance Co:	Claims/Losses:	Amount Paid:



3 YR HISTORY (if you did not have insurance in your name, please indicate companies that you were leased on, or companies for which you were a driver)

VEHICLE SCHEDULE:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10

Year:	Make/Model:	Radius:	GVW:	Value:	Deductible:

DRIVER INFO:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10:

Name:	DOB:	Yrs w/ CDL:	Date of Hire:	Violations:










(Try to be as specific as possible when reporting violations! Give dates, and if speeding, give how much over posted limit. We need prior three year history.)

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COMMENTS:

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North American Transportation Association Inc.
Corporate Office
2533 North Carson Street - Suite 346 - Carson City, Nevada 89706

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