Transportation Insurance

Need by Date (must have 5 days lead time)(Required)

Must haves; All Vehicle information, year, make model, gross vehicle weight, Vehicle ID numbers, Full Driver information, date of birth, driver license number, state licensed, ticket or accidents disclosed, married or single. If you register on this site you will be able to begin the process now after logging in, this is optional, but it is necessary if you would like time to gather some information that you do not have currently. Meaning, you will be able to save and return to "your" questionnaire and not have to start all over. You must complete your request within 20 days or you would have to start all over. If you use the feature to save and continue later you must register. Be on the lookout for an activation email. Also, be on the look out for an return link to return to your application and continue. Any questions? Call 209 223-1870. Note: no coverage is bound in completing this form.

MM slash DD slash YYYY

Has your business been in business for five years or more?

Yes

TRANSPORTATION INSURANCE

We require at least 7 working days lead time and "full and complete" information in order to process your quote request. This form is designed for up to 12 vehicles which include tractors, trucks, trailer, pickups, semi-trailers and Pup trailers.

TOTAL VEHICLES

How many vehicles in total?(Required)

DOT #

TOTAL DRIVERS

How many drivers in total?

CHECK COVERAGE TO QUOTE

Select all that apply

General Liability

Business Auto

Cargo

(OPTIONAL) Select all that apply

Workers Compensaton

Directors & Officers

Office Policy

INSURANCE HISTORY

Have you or do you have prior insurance with no more than a 30 day lapse in coverage?

Yes

Have you or will you provide your insurance claim history within 4 working days?(Required)

Our carriers will not begin working on quotes without prior history "provided you have prior insurance." Some carriers require prior insurance. We write with several carriers. It is required that you order loss runs or provide them in order for us to begin working. If you are a new venture this does not apply to you.

Yes

If you have them now please upload loss runs and prior policy

You may also email loss runs and prior policy to insurance@athenainsurance.com in a separate email. Use a .pdf format. You may also use U.S. postal delivery to 205 Court Street, Jackson CA 95642.

Drop files here or

Accepted file types: pdf, Max. file size: 64 MB, Max. files: 9.

BUSINESS DESCRIPTION OF OPERATIONS

Legal Business Name

Doing Business As...

Is there a DBA?

Yes

Entity Type

Contacts Name and Title with this company

person completing this form

Phone

Fax

Physical Locations

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

Is the "Physical location" the same as the mailing address

Yes

Mailing Address

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

Name of person to contact for inspection

Please provide name of current insurance carrier (if applicable) include expiration date

Please describe your business operations

Is this a new venture?

Yes

Years of experience

Is this your primary business?

Yes

Please describe the other business

Is this a seasonal business?

Yes

Have you ever filed for bankruptcy?

Regarding the bankruptcy... when and explain

Gross receipts for last year?(Required)

"Projected" gross receipts for this next 12 months?(Required)

Is the business for sale?(Required)

Yes

Do you operate in more than one State?

Yes

List of States in which you operate

Do you haul for hire?(Required)

Yes

List Largest Cities entered

Do you operate over a regular route?

Yes

If yes, show town operated between

Are you a common carrier?

Yes

Are you a contract hauler?

Yes

If, yes.. for whom?

List all types of cargo hauled

Do you haul any hazardous or extra hazardous substances or materials as defined by EPA?(Required)

Yes

If yes, please provide complete listing identifying all material(s) and/or chemical content

Do you haul your own cargo exclusively?

Yes

If not, who owns it?

Do you pull double trailers?

Yes

Do you pull triple trailers?

Yes

Do you rent or lease your vehicles to others?

Yes

If yes, upload or email rental or lease agreement for used

If you prefer you may email to insurance@athenainsurance.com and be sure to include the company name and phone number please.

Drop files here or

Accepted file types: pdf, Max. file size: 64 MB, Max. files: 3.

Do you hire any vehicles?

Yes

Please attached a copy of the lease agreement

or email to insurance@athenainsurance.com

Max. file size: 64 MB.

LIABILITY COVERAGE

Complete for desired coverages by indicating limits of insurance.

Combined Single Limit Bodily Injury and Property damage

Medical Payments

Personal Injury Protection *(where available)

DRIVER INFORMATION 1-4

1 Name First & Last

2 Name First & Last

3 Name First & Last

4 Name first and last

1 Marital Status

2 Marital Status

3 Marital Status

4 Marital Status

1 Date of Birth

2 Date of Birth

3 Date of Birth

4 Date of Birth

1 State Licensed

3 State Licensed

1 License Number

1. Class / Type (ie cdl)

2 Class / Type (ie cdl)

EXPERIENCE & DATE OF HIRE

1 Years licensed in class

4 Years licensed in class

2 Type of Unit(S) driven (Bus, Van, Truck, Tractor)

1 Years of Experiences

Number of years of previous "commercial" driving experience

2 Years of Experience

Number of years of previous "commercial" driving experience

1 Date of Hire

DD slash MM slash YYYY

MINORS - Driving Record Minor Violations & Accidents

1 Driving Record Minor Violations & Accidents

Accidents and all moving traffic violations in the Past 5 years. Include date(s) for each violation and accident.

MAJORS - Driving Record cont. Major Violations +

DWI/DUI, Hit & Run, Manslaughter, Reckless Driving, Driving While suspended or revoked, speed contest or other felony. Describe Conviction and date(s) Also, indicate if Employee, Independent Contractor, Owner or Franchise.

1 Majors

Are all drivers covered by Workers Compensation?

Yes

You answered "yes" to workers compensation. Please provide name of carrier

Minimum years driving experience required

Are drivers ever allowed to take vehicles home at night?

Yes

If yes, will family members drive?

Yes

Do you order MVR's on all drivers prior to hiring?

Yes

Drivers Maximum hours daily?

Drivers Maximum hours weekluy?

Do you agree to report all newly hired operators?

Yes

What is the basis for driver pay?

Hourly

Trip

Mileage

Other

Explain "other"

SCHEDULE OF AUTOS/VEHICLES

Describe all vehicles for which application is made for insurance

1 Year Manufactured

1 Make & Model

1 Body Type

Truck, Tractor, Trailer, etc.

1. Vehicle Identification Number

1 Gross Vehicle Weight

1 Total number of rear axles

1 Principal Garaging Location

City and State

1 Radius of operation

1 Annual mileage

1 Anti-lock brakes

Yes

1 Air Bags

Yes

Is vehicle 1 leased?

Yes

Vehicle 1 lessors Address

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