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COMPANY INFORMATION
Phone*: 555-555-5555 Email*:
Company Name:
Address:
City: State:
Zip Code:
MC#:
DOT#:
FEIN# or SSN#:
Expiration Date: Date Needed By:

DRIVER INFORMATION
Driver Name:
Driver License#: State:
DOB:
Experience:

2nd DRIVER INFORMATION
Driver Name:
Driver License#: State:
DOB:
Experience:

TRUCK INFORMATION
Make: Year:
Value($):
VIN#:

2nd TRUCK INFORMATION
Make: Year:
Value($):
VIN#:

COVERAGE NEEDED
Liability:
Cargo Coverage:
Physical damage - Truck:
LEINHOLDER INFORMATION
Name:
Address:
City: State: Zip:
Minimum Driver Underwriting Guidelines

A. No serious or disqualifying traffic violations within the last three years as follows:
1.) Excessive speeding, involving any single offense for any speed of 15 m.p.h. or more above the posted speed limit.
2.) Reckless driving, as defined by state or local law or regulation, including but not limited to the offense of driving a motor vehicle in willful or wanton disregard for the safety of persons or property.
3.) Improper or erratic lane changes.
4.) Following the vehicle ahead too closely.
5.) Driving while intoxicated or under the influence of drugs.
6.) Hit and run, leaving the scene of an accident, or failure to report an accident.

B. No more than four (4) moving violations in the past 36 months, and no more than two (2) moving violations in the previous 12 months.

C. No preventable accidents involving a fatality, bodily injuries treated away from the scene, or disabling damage to a motor vehicle within three years. (Disabling damage means damage that precludes departure of any motor vehicle from the scene of an accident in its usual manner in daylight after simple repairs. This includes damaged vehicles that are drivable, but would incur further damage, if so driven.

D. A minimum of two (2) years experience in the operation of tractor/trailer equipment. E. Must be 23 years old. (Drivers 25 years old and older are encouraged.)

Do you/or your drivers meet the above required guidelines?
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