CONTACT US

Named Insured:
DBA:
Contact Name:
Phone:
Fax:
Tax ID#:
Email address:
DOT#:
MC#:
Currently Insured: YesNo


Address:
_City:_
State:
Zip:
Garaging Address (if different than above)

Limits Requested:

Auto Liabilty: $750,000$1,000,000Hired / Non-owned
Physical Damage: $1,000 Ded$2,500 Ded
Motor Truck Cargo: $50,000$100,000$150,000
MTC Ded:
Trailer Interchange: $25,000$40,000
General Liability: $ 1,000,000 / $2,000,000

Radius Percent
10-50 miles
51-200 miles
201-300 miles
Over 500 miles
Max Radius

Commodities:

Paper productsMachinery / heavy equipmentIntermodal containersFrozen seafoodAuto haulerElectronicsGeneral dry freightGarbage haulerBuilding materialsHousehold goods moverProduceSand & gravel

VEHICLE SCHEDULE

# Year Make SERIAL / VIN# Stated Value GVW
1
2
3
4
5
6
7
8
9

DRIVERS:

# Year Date of Birth Hire Date License # State # Years Exp
1
2
3
4
5

Uploads

IFTAs
Loss Runs
**By completing and signing this application, I am authorizing quotes on behalf of me and my company. The information included is true and accurate to the best of my knowledge. I understand this information is used in rating quotes for my insurance policies. Should the information change, the quote given to me is subject to change.
Signature of Authorized Party
Date Signed
 

Do You Have Any Question?

Call us now at 646-734-0760 or shoot us an email at info@affordableauthority.com. We are happy to talk to you about any question that arises before, during, or after the filing process. We want your business long-term. Ask us your questions and let us show you how we believe in customer service