First
Last
Legal Business Name *
DBA / Trade Name *
Business Phone *
Business Email Address *
Business Address *
Garaging Address *
FEIN/EIN
Business Entity Type
Individual/Sole Proprietor
LLC
Corporation
Partnership
Other
If Other, please specify
Is this a new venture? *
Yes
No
Years in Business *
Years of Commercial Trucking/Transportation Experience *
How did you hear about Adisy Insurance Group?
Facebook
Instagram
Google/Search Engine
Referral
Current Customer
Trucking/Transportation Group
Other
If Other, please specify
Do you have a USDOT number? *
Yes
No
If yes: USDOT Number
MC Number, if applicable
Authority Effective Date
Do you require state or federal insurance filings?
Yes
No
Unsure
If known, what filing(s) do you require?
Motor Carrier / Company Name
Motor Carrier USDOT / MC Number (if known)
Does the motor carrier provide Primary Auto Liability while under dispatch?
Yes
No
Unsure
Are you responsible for maintaining your own insurance while leased onto the motor carrier?
Yes
No
Unsure
If Other, please specify
What is your typical operating radius? *
0-50
51-100
101-200
201-500
Over 500 miles
Do you travel more than 500 miles one way on a single trip? *
Yes
No
Do you cross state lines? *
Yes
No
Estimated Annual Mileage Per Vehicle
What commodities/freight do you haul? *
General Freight
Dry Goods
Consumer Goods
Food Products
Refrigerated Goods
Building Materials
Machinery/Equipment
Automobiles
Electronics
Produce
Household Goods
Containers/Intermodal
Other
If Other, please specify
Please provide an estimated percentage for each commodity hauled.
Do you haul hazardous materials (HazMat)? *
Yes
No
If yes, please describe the hazardous materials.
Year *
Make *
Model *
VIN *
Vehicle Type *
Stated Value / Current Vehicle Value *
Vehicle Ownership *
Owned
Financed
Leased
Garaging ZIP Code *
Estimated Annual Mileage
Was this vehicle purchased within the last 45 days?
Yes
No
If No: Purchase Date and Purchase Price.
Are there any customizations, modifications, permanently attached equipment, or aftermarket equipment?
Yes
No
If yes, describe and provide estimated value.
Year (V2)
Make (V2)
Model (V2)
VIN (V2)
Vehicle Type (V2)
Stated Value / Current Vehicle Value (V2)
Vehicle Ownership (V2)
Owned
Financed
Leased
Garaging ZIP Code (V2)
Estimated Annual Mileage (V2)
Was this vehicle purchased within the last 45 days? (V2)
Yes
No
If yes: Purchase Date and Purchase Price (V2)
Are there any customizations, modifications, permanently attached equipment, or aftermarket equipment? (V2)
Yes
No
If yes, describe and provide estimated value (V2)
Year (V3)
Make (V3)
Model (V3)
VIN (V3)
Vehicle Type (V3)
Stated Value / Current Vehicle Value (V3)
Vehicle Ownership (V3)
Owned
Financed
Leased
Garaging ZIP Code (V3)
Estimated Annual Mileage (V3)
Was this vehicle purchased within the last 45 days? (V3)
Yes
No
If yes: Purchase Date and Purchase Price (V3)
Are there any customizations, modifications, permanently attached equipment, or aftermarket equipment? (V3)
Yes
No
If yes, describe and provide estimated value (V3)
Do you own or operate trailers?
Yes
No
Do you pull trailers you do not own?
Yes
No
If yes, what is the maximum value of any non-owned trailer in your possession?
Do you need coverage for physical damage to trailers you do not own?
Yes
No
Unsure
Year
Make
Type
VIN
Stated Value: $
Year (T2)
Make (T2)
Type (T2)
VIN (T2)
Stated Value: $ (T2)
Year (T3)
Make (T3)
Type (T3)
VIN (T3)
Stated Value: $ (T3)
Full Legal Name *
Date of Birth *
Driver's License Number *
Driver's License State *
License Type / Class *
CDL Number (if different)
CDL Class
Original CDL Issue Date (if known)
Years Licensed in Current Class *
Total Years of Commercial Driving Experience *
Years of Experience Driving This Type of Vehicle
Driver Status *
Owner
Employee
Owner-Operator – Leased Driver
Other
If Other, please specify
Date Hired / Date Driver Began Working With Company
Has this driver had any accidents during the past 5 years?
Yes
No
If yes, provide details.
Has this driver had any moving violations/tickets during the past 5 years?
If yes, provide details.
Has this driver's license ever been suspended or revoked?
Yes
No
If yes, explain.
Any major violations, including DUI/DWI, reckless driving, or leaving the scene of an accident?
Yes
No
If yes, explain.
Full Legal Name (D2)
Date of Birth (D2)
Driver's License Number (D2)
Driver's License State (D2)
License Type / Class (D2)
CDL Number (if different) (D2)
CDL Class (D2)
Original CDL Issue Date (if known) (D2)
Years Licensed in Current Class (D2)
Total Years of Commercial Driving Experience (D2)
Years of Experience Driving This Type of Vehicle (D2)
Driver Status (D2)
Owner
Employee
Owner-Operator – Leased Driver
Other
If Other, please specify (D2)
Date Hired / Date Driver Began Working With Company (D2)
Has this driver had any accidents during the past 5 years? (D2)
Yes
No
If yes, provide details. (D2)
Has this driver had any moving violations/tickets during the past 5 years? (D2)
If yes, provide details. (D2)
Has this driver's license ever been suspended or revoked? (D2)
Yes
No
If yes, explain. (D2)
Any major violations, including DUI/DWI, reckless driving, or leaving the scene of an accident? (D2)
Yes
No
If yes, explain. (D2)
Full Legal Name (D3)
Date of Birth (D3)
Driver's License Number (D3)
Driver's License State (D3)
License Type / Class (D3)
CDL Number (if different) (D3)
CDL Class (D3)
Original CDL Issue Date (if known) (D3)
Years Licensed in Current Class (D3)
Total Years of Commercial Driving Experience (D3)
Years of Experience Driving This Type of Vehicle (D3)
Driver Status (D3)
Owner
Employee
Owner-Operator – Leased Driver
Other
If Other, please specify (D3)
Date Hired / Date Driver Began Working With Company (D3)
Has this driver had any accidents during the past 5 years? (D3)
Yes
No
If yes, provide details. (D3)
Has this driver had any moving violations/tickets during the past 5 years? (D3)
If yes, provide details. (D3)
Has this driver's license ever been suspended or revoked? (D3)
Yes
No
If yes, explain. (D3)
Any major violations, including DUI/DWI, reckless driving, or leaving the scene of an accident? (D3)
Yes
No
If yes, explain. (D3)
Are you currently insured? *
Yes
No
If yes: Current Insurance Carrier
Current Policy Expiration Date
How much are you currently paying for insurance?
What is your target insurance budget?
If Other, please specify
Have you received any other insurance quotes recently?
Yes
No
Carrier / Insurance Company
Quoted Premium: $
Have you had any insurance claims or losses during the past 5 years? *
Yes
No
Date of Loss
Type of Loss
Driver
Amount Paid / Reserved
Description of Loss
Have you had any insurance claims or losses during the past 5 years? (L2)
Yes
No
Date of Loss (L2)
Type of Loss (L2)
Driver (L2)
Amount Paid / Reserved (L2)
Description of Loss (L2)
If Other, please specify
I'm unsure - please help me determine which coverages I need.
Do you need Bobtail Liability or Non-Trucking Liability?
Bobtail
NTL
Both
Neither
Unsure
Do you need Workers' Compensation?
Yes
No
Unsure
Do you need Occupational Accident coverage?
Yes
No
Unsure
Auto Liability Limit Requested
$750,000
$1,000,000
Other
Unsure
If Other, please specify
Motor Truck Cargo Limit
$50,000
$100,000
$150,000
$250,000
Other
Unsure
If Other, please specify
Physical Damage Deductible
$1,000
$2,500
$5,000
Other
Unsure
If Other, please specify
General Liability
$1M
$2M
Other
Unsure
If Other, please specify
Trailer Interchange Limit Requested
How soon are you looking to start your policy? *
Immediately
Within 7 days
Within 15 days
Within 30 days
At expiration-renewal of current policy
If Other, please specify
Requested Policy Effective Date *
Is there anything else we should know about your business, operation, drivers, vehicles, insurance needs, or upcoming changes?
Address *
Email *
Phone Number *
Driver's License # *
Date of Birth *
Electronic Signature / Full Name *
Date *
