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Agency Information
Commonwealth Underwriters Agent Code: *Note: this field is optional*

Agent Name:
Agency Name:
Would you like a Finance Quote?
Agency Mailing Address
Agency Mailing City
Agency Mailing State
Agency Mailing Zip
Agency Phone Number:
Agent Email Address: (A copy of the quote will be sent to this address)
Insured Information
Insured Name:
Insured Email: (will only be used to communicate regarding this account)
Insured Phone Number:
Insured Address:
Insured Zip
Year Established:
If year established cannot be filled or does not apply please leave blank.
Insured ICC Docket Number: MC
Are filings required?
Does this quote include all owned/operated units?
Type of Company/Carrier:
Does the insured also carry their own goods?
Please describe Carrier details:
Is Primary Garaging Address the same as the Insured's Address? (Click if Yes)
Primary Garaging Address:
Garaging Zip
Does insured have any other Garaging Addresses?
Alternate Garaging Address 1
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Garaging Address
Garaging City
Garaging State:
Garaging Zip Code
Has insurance coverage for this applicant ever been placed through Commonwealth Underwriters, Ltd.? (Click if Yes)
Has this applicant ever operated under a different name? (Click if Yes)
Please give details of any operations carried out other than that of a carrier:
If no other operations are performed please fill in "N/A".
Does insured subcontract to other parties?
  • For physical damage quotes only, select "No".
Is subcontracting for long term (30+ days) leases or other basis?
Please describe subcontracting lease basis:
Are subcontractors responsible and insured for loss or damage to cargo?
Does insured maintain copies of sunbcontractor current insurance arrangements on file?
Prior Carrier
Has the insured had coverage in the last 3 years?
Has the insured had consecutive coverage for all lines being quoted for the last 12 months?
Is prior cargo coverage information known? (Click if Yes)
Has any insurer within the past 3 years refused to renew or canceled insurance on the applicant?
Please give details:
Prior Carrier Name:
Prior Perils Form:
Policy Premium: $
Policy Deductible: $
Policy Limit: $
Policy Expiration Date:
Was a renewal offer made?: (Click if Yes)
Is the owner also listed as a driver?
This will decline this quote. However, if you complete the rest of the form and submit it, it will be reviewed by an underwriter.
How many years of experience does the applicant have in the same type of work and/or exposure being submitted?
Is the prior employment information known?
Employer 1
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Employer Name:
Employer Address:
Employer City:
Employer Zip:
Employer State:
Employer Phone Number:
Dates of Employment: -
Unit Type:

Do you object to verification of the above information?
Quote Type
What type of Quote would you like?
Owner 1
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Owner Name:
Please detail the steps taken in employing new drivers.
What are the grounds for firing a driver?
Driver 1
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Driver Name:
Date of Birth:
License Number:
License State:
Years Experience:
Date of Hiring:
Violation History Known? (Click if Yes)
Number of minor violations:
Number of major violations:
Number of at-fault accidents:
Unit 1
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Is the VIN number for the unit known?
Unit Type:

Are there any trailers to schedule?
Does insured own or use equipment other than those listed above?
Are vehicles rented each time there is a job?
Does insured lease, loan, or rent any of the equipment to others?
Are all vehicles titled under named insured?
At what intervals?
Do any units have a Gross Vehicle Weight greater than 26,000 lbs (Click if Yes)
Do any drivers have less than 2 years with a Commercial Driver's License Class A (CDL-A)?
Please detail any steps taken to secure vehicles.
Risk Qualification
Does applicant require terminal coverage?
Terminal Coverage is required if any vehicle will be parked in any one location for more than 72 hours and up to 30 days.
Cargo Limit per Unit: $
Limits of Insurance up to $100,000 for any one scheduled vehicle; or $200,000 for any one disaster (if more than one vehicle scheduled). For Higher limits, please contact your underwriter.
Average Exposure per Unit: $
Maximum Exposure per Unit: $
Does insured ever carry loads greater than the cargo insurance limit requested?
What is the Radius of Operations?
Cargo Deductible:
  • Default deductible is $1,000 for all classes, except $2,500 for refrigeration breakdown coverage and Household Goods movers.
Does the cargo include liquor products or manufactured tobacco?
Does the cargo include any oversized or overweight commodities?
Does the cargo include any of the following commodities or types of operations: (Check if Yes)
  • Baled Cotton
  • Chemicals
  • Computers and Computer Components
  • Copper and other precious metals and/or alloys
  • Eggs
  • Exotic Animals
  • Explosives
  • Fine Art
  • Firearms
  • Furs
  • Gold/Silver
  • Jewelry
  • Money, Currency, and/or Coins
  • Oriental Rugs
  • Oversized and/or Overweight Cargo
  • Pharmaceuticals
  • Photographic Film
  • Shellfish

These types of cargo or options will decline this quote. However, if you complete the rest of the form and submit it, it will be reviewed by an underwriter.

Please Select All Commodities Carried:



Building Materials

Consumer Goods

Food Products

Machinery Equipment


Total Percentage: %

Refrigeration Breakdown
Does applicant require refrigeration breakdown coverage?
Are any trailers older than 10 years?
Is reefer trailer serviced at least once every 30 days?
Any seafood or shellfish hauling?
Districts of Operation
Please select all States and Provinces in which the Insured operates:
Gross Receipts
Please give gross receipts in respect of your trucking operation for past 4 years.
What is the estimated Gross Revenue for the coming year? $
Applicant is considered a new venture and as such would not have Gross Reciepts for Prior Years.
Receipt Year:
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Own Haul Total: $
Subcontracted Total: $
Have there been any losses in the last 3 years?
Please report all losses for the past 3 years
Loss 1
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Loss Year:
Premium: $
Losses Paid and Outstanding
Type Paid / Outstanding
$ / $
Please describe loss type:
Terrorism Coverage
Would contractor like Terrorism Coverage (TRIA)? (Click if yes)
GL Information
Would the insured like GL coverage? (Click if Yes)
Please select a limit
Owner and office payroll (not including drivers and warehouse workers): $
Does the insured have a commercial auto liability policy in place?
If Yes, Limit:
Is any work subcontracted?
Cost of subcontractors: $
Is there any warehousing of goods?
What is the warehouse payroll? $
Are there any additional insureds? (Click if Yes)
Type of additional insureds:
Number of additional insureds:
What commission would you like for this account?
Any Additional Comments:

Any questions or problems with the form? Please contact Amy Nelson 800-396-6226 x119

Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.