Intake Form | Elite International Insurance Services

Intake Form

Applicants Name

USDOT

DBA

Other State Filling

Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Same as Garaging Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Financial Responsibility, Name

Years in Business

DOB

DL#

COMMODITIES HAULED

Commodities

% of Loads

Type (Tractor, Dry Van, Flat Bed, etc.)

Do you own what you haul?

Yes

RADIUS OF OPERATION

Radius of Operation

Zone

% of Loads

Zone: 0-100 miles, 100 - 300 miles, 300 - 500 miles, 500+ miles

Notes

COVERAGES

Auto Liability

PIP

Pysical Damage

Cargo

General Liability

Umbrella

Excess

Other

Deductibles

DRIVERS LIST

Drivers List

Driver Name

License #

State

Date Of Birth

Year of Experience

Date of Hire

VEHICLE LIST

Vehicle List

Year

Make

Type (Tractor, Dry Van, Flat Bed, etc.)

VIN #

Value

TRAILER LIST

Trailer List