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 First NameLast NameDate Of BirthCDL# (if available)Home Phone Number
 Company Name (Inc, LLC or Sole Proprietor)USDOT# (if not available put 0's)Do you have to have state, interstate, ICC or FHWA Filings?Years In Business
 AddressCityStateZip CodeE-Mail AddressWork Phone Number
 If Loss Runs Not Available Provide Insurance Company's Name For Past 3 years. If New Venture Put "New"Attach Loss Runs (if available)
 Driver's First and Last NameDate of BirthCDL License NumberYears of CDL ExperienceNo. of Accidents in the last 3 YearsNo. of Violations in the last 3 Years
 If you have other drivers list all the same information as above. If not, put N/A
 YearMake and ModelVINValue
Tractor
Trailer
 If you have other tractors/trailers list all the same information as above. If not, put N/A
$25,000$50,000$75,000$100,000$150,000$250,000
Amount of Insurance
$300,000$500,000$750,000$1,000,000
Limits of Liability
0-100101-300301-500500+
Mile Radius of Operation
 City 1City 2City 3
3 Major Cities You Travel To
 Type of Cargo/Commodities and Percentages of It
 Any comments or questions
Fleet Application. Only fill out for 6+ units. E-mail to kevin@statecoinsurance.com :