Fortenberry Insurance Agency

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Date:

* Applicant:

(Individual Name/Owner)

* Email Address:

* Phone #:

Cell #:

D/B/A:

Garage Address:

Street:	City:	State:	Zip:

(Where you park your trucks)

*Coverage Needed:

Primary Coverage	Liability
	Physical Damage
	Cargo

Non-Trucking (Bobtail) and Physical Damage
Personal Injury Protection State Minimum
Uninsured / Underinsured Motorist State Minimum

Liability Limits:

Amount:

Other:

ICC/FHWA Filings:

MC#:
DOT#:
TXDOT#:

Other Coverages:

Non-Owned Trailer Physical Damage:
General Liability:

Miles Traveled Radius:

(Furthest Destination)
PLEASE FAX IFTA REPORT TO 254-776-3381

States Traveled:

Major Cities Traveled:

Cargo Limit:

Amount:	Other:	(Keep in mind that most shippers will require a $100,000 limit)

Commodities:

#1:

#2:

#3:

#4:

Commodities:	%:	Value of Avg. Load:	Max value of Load:




(Example: Lumber	45%	$30,000	$50,000

Years in Business:

Expiration Date:

Prior Carrier Info:

1st Year:

2nd Year:

3rd Year:

Dates:	Insurance Co:	Claims/Losses:	Amount Paid:



3 YR HISTORY (if you did not have insurance in your name, please indicate companies that you were leased on, or companies for which you were a driver)

Details of Claims Paid:

Vehicle Schedule:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10

Year:	Make/Model:	Radius:	GVW:	Value:	Deductible:

Driver Info:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10:

Name:	DOB:	Drivers License #:	Date of Hire:	Violations:










(Try to be as specific as possible when reporting violations! Give dates, and if speeding, give how much over posted limit. We need prior three year history.)

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