1DOT #2Company Information3Vehicles4Drivers5Coverage Desired6Previous Claims7Uploads8Contact Information What is the name of your company? Do you have a DOT #?Do you have a DOT #?YesNo, not neededNo, going to applyDOT Number What do you do? Tractor/trailer: Reefer Tractor/trailer: Dry Van Tractor/trailer: Auto Hauler Tractor/trailer: Flatbed Box Truck Cargo Van Something else? What do you do? Where do you go?Choose all that apply (you can choose more than one)48 States12 WesternAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow many years have you had prior insurance in your name?How many years have you had prior insurance in your name?0, this is a new venture0, lapse over 30 days12345+What best describes your business's ownership structure? Individual/Sole Proprietor Partnership LLC Corporation Trust Mailing Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Where You Park Your Truck Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What freight do you haul? Name of ELD vendor? Power UnitsClick add power unit button to add a vehicle. Year Make Model VIN Number Actions Edit Delete There are no Power Units. Add Power Unit Maximum number of power units reached. TrailersClick add trailer button to add a trailer. Year Make Model VIN Number Actions Edit Delete There are no Trailers. Add Trailer Maximum number of trailers reached. Business Owner Name First Last Date of Birth MM slash DD slash YYYY License Number License StateLicense StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIs the owner a driver?Is the owner a driver?Owner is primary driverOwner is a backup driverOwner is not a driverYears CDL ExperienceAdditional Drivers Name Actions Edit Delete There are no Additional Drivers. Add Additional Driver Maximum number of additional drivers reached. Auto LiabilityAuto LiabilityNot Requested1 Million750,000OtherCargoCargoNot Requested100,000150,000200,000250,000500,000OtherPhysical DamagePhysical DamageNot Requested1000 ded2500 dedGeneral LiabilityGeneral LiabilityNot Requested1,000,000/2,000,000Trailer InterchangeTrailer InterchangeNot Requested20,00030,00040,00050,00060,000OtherAdditional Services Occupational Accident Work Comp Roadside Assistance Other Any accidents or claims last 3 years? Yes No Date MM slash DD slash YYYY Amount Paid Details Driver License Copies (optional) Drop files here or Select files Max. file size: 200 MB. Vehicle Registrations (optional) Drop files here or Select files Max. file size: 200 MB. IFTA Reports (optional) Drop files here or Select files Max. file size: 200 MB. Loss Runs (optional) Drop files here or Select files Max. file size: 200 MB. Current Certificate of Insurance (optional) Drop files here or Select files Max. file size: 200 MB. Questions, concerns, special requests? First Name* Last Name* Email* Phone*Where did you hear about us?*Please select...Google AdGoogle SearchSocial MediaReferralWebsiteOtherCommentsThis field is for validation purposes and should be left unchanged. Δ Ask a quick question Name* Email* Tell us a bit about your question or request. Δ Meet Chuck Chuck the Truck Duck Call or text: 916-572-9815 chuck@truckduck.com ALEXRUE.com Please refer to the actual policy and/or endorsements for terms, conditions, coverage’s, limitations, exclusions and premium. 916-572-9815      CA License # 0H08143