Commercial Auto Insurance Application Transportation, NOT FOR HIRE: "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY Applicants Name*DBAMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code FEINDOT# if ApplicablePhone Number*Email Address* Address of Garage Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Operational informationHas the applicant previously operated under another name? Yes No List all names in the past 5 yearsDo any of the units that are being scheduled have specialized equipment to aid in the transportation of disabled passengers? Yes No List all special equipmentAre other units used in the business that are not being scheduled? Yes No Does the applicant have vehicles titled in their name that are not scheduled? Yes No Does the insured ever transport for Uber, Lyft or a similar Ride Share company? Yes No General Radius of Resident/ClientsWhat Maintenance Program is in placeSelect OptionContracted Mechanic ScheduleSelf Maintenance ScheduleDo You Pull Yearly MVR Reports for Each Driver Yes No Vehicle and Driver Information: You will be contacted by an Agent to go over the Driver and Vehicle information requirements after receiving the attached application. This is due to Commercial Auto information demands and security requirements. Thank you for allowing us to find your best options, year after year.Untitl* I acknowledge and agree to submit this information
