Long Haul Application: Section 1 of 4

Required for movers that operate on their own authority beyond a 200-mile radius, or that are responsible for primary coverage under van line authority. Please attach your last 4 quarters of IFTA (International Fuel Tax Agreement) reports.

Named Insured – business / entity name (full legal name, e.g. “ABC Plumbing, LLC”)

Coverage requested (type of coverage, amount / limits and deductible)

What year did you start your business?

Physical street address

City

County

State

Zip Code

Is the mailing address different from the physical address?

YesNo

Contact Person – your first and last name

Title (owner, manager, partner, etc.)

Primary phone

Cell / Business / Home

CellBusinessHome

Secondary phone (optional)

Cell / Business / Home

CellBusinessHome

Primary email

Secondary email (optional)

Do you have a website?

YesNo

USDOT #

MC #

Van line (if any)

Total annual mileage for ALL operations, including short hauls

Total annual mileage over 200 miles under your own authority

Total annual mileage over 200 miles under van line authority where you must provide coverage

Total annual revenue over 200 miles under your own authority

Total annual revenue over 200 miles under van line authority where you must provide coverage

Number of units dedicated to the van line fleet (any unit used at least 80% of the time)

What percentage of your long haul units are:

Employee driven (%)

Owner-operator driven (%)

Do any long haul drivers have less than two years of over-the-road experience?

YesNo

Are there any long haul drivers under the age of 25?

YesNo

Are your long haul drivers team drivers or solo drivers?

TeamSoloBoth

Describe your long haul operations (regular routes, special contracts, hauling under other authority)

IFTA reports - last 4 quarters

Optional. Upload your last 4 quarters of IFTA reports (PDF, image, Word or Excel, up to 10 MB each, 5 files max), or send them to your agent later.

Annual revenue - last 12 months

Next 12 months

Full-time employees

Part-time employees

Occupied area (square feet)

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Section I. General Information