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TRUCK INSURANCE COMPANY IN MARYLAND & VIRGINIA
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1 Step 1
ABOUT YOUR BUSINESS
Business Cardupload
cloud_uploadYou can also upload your business card here
1.
Business namebusiness name
Doing Business As (DBA)DBA
Years in BusinessYears in business
2.
What type of business (eg. towing, delivery, general freight, etc) please give us specific details/description of your type of businessmore details
0 /
3.
Do you have a DOT number?
DOT #DOT number
4.
Are you a sole proprietor, a partnership, or corporation (LLC - Inc.)?ownership
5.
Is your commercial vehicle currently insured?Insured vehicle
Name of your current insurance carriercurrent insurance
Expiration date (dd/mm/yyyy)
date_range
6.
Year business began
date_range
7.
Does your business have either General Liability or Business Owner Protection policy?
8.
Federal Employer Identification Number (FEIN number)FEIN
10
0
100
ABOUT THE DRIVERS
Driver's licenseupload
cloud_uploadYou can also upload the driver’s license of the person to be insured here
9.
Name of Insured driverinsured driver
Date of Birth (dd/mm/yyyy)DOB
date_range
Driver License State and Numberlicense state & number
Is this a Commercial Driver's License?
Do you have more insured drivers?
Name of Insured driver #2insured driver
Date of Birth (dd/mm/yyyy) #2DOB
date_range
Driver License State and Number #2license state & number
Is this a Commercial Driver's License? #2
Name of Insured driver #3insured driver
Date of Birth (dd/mm/yyyy) #3DOB
date_range
Driver License State and Number #3license state & number
Is this a Commercial Driver's License? #3
Name of Insured driver #4insured driver
Date of Birth (dd/mm/yyyy) #4DOB
date_range
Driver License State and Number #4insured driver
Is this a Commercial Driver's License? #4
Name of Insured driver #5insured driver
Date of Birth (dd/mm/yyyy) #5DOB
date_range
Driver License State and Number #5license state & number
Is this a Commercial Driver's License? #5

If you have a fleet of more than 5 vehicles/drivers, please contact our office for an accurate quote

10.
Is the company owner the same as the driver to be insured?
Addressaddress
Owner's namename
Date of Birth (dd/mm/yyyy)DOB
date_range
Owner's Addressowner address
Company's Addressaddress
11.
Do you need SR22 or other state/ federal filings?
12.
Any accidents or tickets?
Please tell us when and the type of traffic incidentaccident details
0 /
10
0
100
ABOUT THE COMMERCIAL VEHICLE(S)
Vehicles / Registrationsupload
cloud_uploadYou can also upload a picture of your vehicle(s) and/or the registration(s) here)
13.
VIN numberVIN
Maximum number of miles traveled in a trip (one way)
Type of vehicle: Ex Van, truck, bus, etc.VIN
Garaging zip: Ex 22002
Yearyear
Makemake
Modelmodel
Does the vehicle need collision coverage?
Do you need loss payee?
Do you have more vehicles?
VIN number #2VIN
Maximum number of miles traveled in a trip (one way) #2
Type of vehicle: Ex Van, truck, bus, etc. #2VIN
Garaging zip: Ex 22002 #2
Year #2year
Make #2make
Model #2model
Does the vehicle need collision coverage? #2
Do you need loss payee? #2
VIN number #3VIN
Maximum number of miles traveled in a trip (one way) #3
Type of vehicle: Ex Van, truck, bus, etc. #3VIN
Garaging zip: Ex 22002 #3
Year #3year
Make #3make
Model #3model
Does the vehicle need collision coverage? #3
Do you need loss payee? #3
VIN number #4VIN
Maximum number of miles traveled in a trip (one way) #4
Type of vehicle: Ex Van, truck, bus, etc. #4VIN
Garaging zip: Ex 22002 #4
Year #4year
Make #4make
Model #4model
Does the vehicle need collision coverage? #4
Do you need loss payee? #4
VIN number #5VIN
Maximum number of miles traveled in a trip (one way) #5
Type of vehicle: Ex Van, truck, bus, etc. #5VIN
Garaging zip: Ex 22002 #5
Model #5model
Year #5year
Make #5make
Does the vehicle need collision coverage? #5
Do you need loss payee? #5

If you have a fleet of more than 5 vehicles/drivers, please contact our office for an accurate quote

10
0
100
ABOUT YOU
14.
Nameyour full name
Phonephone
15.
Where can we contact you?contact
Prefered time to contact youcontact time
alarm
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ACG Insurance Company
ACG Insurance Company