Florida Commercial Auto & Fleet Insurance Application | Hendrickson Insurance, Sarasota FL

A. Business Information

Legal / named insured *

Required.

DBA (doing business as)

FEIN

Website

Contact name *

Required.

Title

Phone *

Required.

Email *

Enter a valid email.

Mailing address

Primary garaging address *

Required.

City

State

ZIP

Years in business

Years under current ownership

B. Operations & Radius

Describe your operations / what you haul or do *

Required.

Industry / NAICS

Radius of operation

Local under 50 miles Intermediate 50 to 200 miles Long-haul over 200 miles

States of operation

USDOT number

MC / docket number

Carrier type

Private carrier (own goods) For-hire

Annual gross receipts

Annual mileage all vehicles

C. Drivers

List every driver who will operate a covered vehicle. All drivers must be listed, and we pull motor vehicle records (MVRs) on each one before quoting. Use the sliders to add each additional driver.

Number of drivers

Minimum driver age

Years commercial driving required

Driver 1

Full name

Date of birth

Driver's license number

DL state

Years experience

Date of hire

CDL class

A B C None

Add a second driver

Driver 2

Full name

Date of birth

Driver's license number

DL state

Years experience

Date of hire

CDL class

A B C None

Add a third driver

Driver 3

Full name

Date of birth

Driver's license number

DL state

Years experience

Date of hire

CDL class

A B C None

Add a fourth driver

Driver 4

Full name

Date of birth

Driver's license number

DL state

Years experience

Date of hire

CDL class

A B C None

More than four drivers? List the rest (name, DOB, DL#, state, CDL, experience)

D. Vehicles / Fleet

List every power unit and trailer to be covered, including spares and seasonal units. Use the sliders to add each additional vehicle.

Number of vehicles

Vehicle 1

Year

Make

Model

VIN

GVW class

Cost new / stated value

Garaging ZIP

Ownership

Owned Financed Leased

Lienholder or lessor

Primary use

Radius

Local Intermediate Long-haul

Add a second vehicle

Add a third vehicle

Add a fourth vehicle

More than four vehicles? List the rest (year, make, model, VIN, type, value)

E. Coverage Requested

Auto liability limit / CSL (e.g. 1,000,000)

Medical payments / PIP

Uninsured / underinsured motorist

Yes No Match

Comprehensive deductible

Collision deductible

Optional coverages of interest

Motor truck cargo limit requested

Cargo commodity hauled

F. Safety & Loss Control

G. Prior Insurance & Loss History

Current carrier

Policy expiration date

Years continuously insured

Current liability limit

If yes, list date, type, amount, and at-fault

H. Acknowledgement

I certify that the information above is true and complete to the best of my knowledge. Submitting this form does not bind coverage; coverage is subject to underwriting approval and payment of premium.

Typed signature (full name) *

Required.

Date *

Required.

I agree to the statement above. *

Please confirm to submit.

Commercial auto application.

A. Business Information

B. Operations & Radius

C. Drivers

D. Vehicles / Fleet

E. Coverage Requested

F. Safety & Loss Control

G. Prior Insurance & Loss History

H. Acknowledgement

Thank you — application received

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