John Galt Insurance Agency

Trucking application

Company Information

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Garage location for the vehicle(s)

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Description of your operation

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Is this a new
trucking venture? *
DOT Cargo Codes
 Please select
A - General freight
AA - Farm supplies
B - Household goods
BB - Construction
C - Metal, sheets or coils
CC - Water, well
D - Motor vehicles
DD - Other
E - Driveaway or Towaway
F - Logs, poles or lumber
G - Building Materials
H - Mobile Homes
I - Machinery or Large objects
J - Fresh produce
K - Liquids, gases
DOT Cargo Codes
 Please select
L - Intermodal containers
M - Passengers
N - Oilfield equipment
O - Livestock
P - Grain, feed or hay
Q - Coal
R - Meat
S - Garbage, trash
T - U.S. Mail
U - Chemicals
V - Commodities or Dry Bulk
W - Refrigerated foods
X - Beverages
Y - Paper products
Z - Utility
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Are you planning to
hire more drivers or
add more trucks in
the next 12 months? *
Do rent or lease your 
vehicles to others? *
Do you currently use an ELD
(Electronic Logging Device)? *
Do you haul
for hire? *
Do you operate
on a regular
route? *
Do you haul
hazardous
materials? *
Do you hire any 
other vehicles? *
Are you a tow truck? *
Do you do Repos?
Do you operate 24-7?

Owner(s) Driver License information

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1) DL State - 2) LIC# - 3) CDL Class (A, B or C) - 4) # of Years licensed in class or Year CDL obtained
 *
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Driver(s) information

1) Driver's Name - 2) DOB - 3) DL State - 4) LIC# - 5) CDL Class (A, B or C) - 6) # of Years licensed in class or Year CDL obtained
 *
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Do you have more than
one driver per truck? *
Do they team or 
split the driving? *
Any driving violations
or accidents in the
past 3 years? *
Details
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Are all scheduled vehicles 
owned by this entity? *
Lein Holder(s) *
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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
Do you have any trailers? *

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 (if applicable)
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
Auto Liability
Physical Damage
Cargo
Collision
Comprehensive
Individual Named Insured
Fire and Theft with CAC (Combined additional Coverage)
Non Owner Trailer
General Liability
Workers' Comp
Rental Reimbursement with Downtime
Bobtail Coverage
Trailer Interchange
Umbrella
Medical Payments
Uninsured Motorist
Garage Keepers Liability (Tow Trucks only)
On-Hook Towing (Tow Trucks only)
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Internal use only

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