John Galt Insurance Agency

CNR Application

Company Information

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Description of your business

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Are you a Daycare 
or Private School? *
Do you currently pay in
excess of $10,000 annually

for all of your business 
insurance combined?
 *
Does your company currently offer Health 
Care, Life, Dental, Disability or a 401k plan
to your employees?
 *
Do you have any
company vehicles? *
Do any of those
vehicles have
trailers? *
Are all scheduled vehicles 
owned by your company? *
Lein Holder(s) *
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Any insurance claims in the past year? *
Explain those claims in detail
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Enrollee Information

Note that this information is needed not only for the employee, but also for any of their dependents also on their coverage.

Enrollment Type - Employee only (EO), Employee + Spouse (ES), Employee + Children (EC) or Family (F)

1) First & Last Name 2) Enrollment Type (EO, ES, EC or F) 3) Home Zip Code 4) Gender (M or F) 5) DOB
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Vehicle information

1) Year - Make / Model - 2) Vin# - 3) GVW - 4) GVW Class (1-9) - 5) Vehicle's Value - 6) Leased/Owned/Financed
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Type of truck
 Please select
Agricultural
Box or Straight
Bucket or Cherry Picker
Bus
Car Carrier or Rollback
Catering or Lunch
Cement Mixer
Deliver Van
Dump
Flatbed
Front Loader
Garbage
Garbage (Roll-on)
Type of truck
 Please select
Ice Cream
Pick Up
Pump
Refrigerated
Stake Body
Step Van
Street Sweeper
Tank
Tow or Wrecker
Truck Tractor
Wheelchair Bus
Other

Trailer information

1) Year - Make / Model - 2) Vin# - 3) GVW - 4) GVW Class (1-9) - 5) Vehicle's Value - 6) Leased/Owned/Financed
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Type of trailer
 Please select
Auto Hauler
Bottom or Side Dump
Bulk Commodity
Concession
Dry Freight
Dump Body or Transfer Box
Pole
Refrigerated
Tank
Rag Top
Flatbed
Gooseneck
Horse
Livestock
Logging
Low-Boy
Tilt
Travel
Utility
Connection to the Trailer
 Please select
5th Wheel Hitch
Bumper Hitch
Front Mount Hitch
Gooseneck Hitch
Pintle Hitch
Receiver Hitch
Weight Distribution Hitch

Insurance information

Type of coverage
 Amount of coverage requested
Property
Wind
Flood
General Liability
Professional Liability
Workers' Compensation
Commercial Auto
Umbrella
Other
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Internal use only

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