25329 Interstate 45 N, Suite 101 The Woodlands, TX 77380

1-866-TEXAS-45
(1-866-839-2745)

Our Texas Insurance Policies & Coverages

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Truck Insurance - Texas Based Businesses

Long Haul Trucking Insurance - Cargo Insurance

We offer insurance protection for Tractor Trailers, Straight Trucks, Service Trucks, Vans Commercial Autos, Hot Shot Operators and Pickup Trucks.

Print Out Microsoft Word Submission - Fill Out and Fax Back To Us

Truck Ins_Small Fleet Application - Microsoft Word Submission

Or Fill Out Our On-Line Rater

Please provide the following information:

Insured Information:

Name

Business Name

Type Of Business (Sole Prop/Inc/LLC/Other)

Street Address

City

State/Province

Zip/Postal Code

County

Garaging Address

Garaging - City

Garaging - State/Province

Garaging - Zip/Postal Code

Garaging - County

Work Phone

Home Phone

Tax ID # or Social

FAX

E-mail

Years in Business:
Effective Date:
Business Description:
Schedule of Vehicles/Trailers
Year Make VIN GVW
ACV-Actual CashValue
Radius Traveled

Average Trip Distance
(Rating Question)
Largest Cities Entered:
Atlanta Boston Buffalo Charlotte
Chicago Cincinnati Cleveland Dallas/Fort Worth Denver
Detroit Hartford Houston Indianapolis Jacksonville
Kansas City Little Rock Los Angeles Louisville Memphis
Miami Milwaukee Minneapolis/
St. Paul		 Nashville New Orleans
New York City New Orleans Oklahoma City Omaha Philadelphia
Phoenix Pittsburgh Portland Richmond St. Louis
Salt Lake City San Diego San Francisco Seattle Tulsa
Other Cities:
Commodities Hauled - Percentages Of Each
Leasing Info
Number of owned units:
Number of leased units:
Is insured hauling for hire? Yes No
Driver Information
Name
DOB
CDL Number & State
Experience
Date of Hire/Lease
MVR Info
Coverages
Liab CSL: Excess Liab: U/M: PIP:
Comp. DED: SCOL DED: Coll. DED: Med Pay:
Cargo Limit: Cargo DED: Reefer Breakdown: Excess Cargo:
Non-trucking: GL CSL: Payroll: Other:
MC#: TxDOT: USDOT:
Leased to:
Address:
3-Year Prior Carrier and Loss History
Carrier No. of Losses Total $ Amount
Current Year
1st Prior Year
2nd Prior Year
Has previous coverage been cancelled or denied? Yes No
If so, please explain why:
Comments