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KBSK Insurance LLC, Suite 200 3950 Sunforest Court Toledo, Ohio 43623
734-597-1007
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Coverage
Commercial & Business
General Liability Truck Insurance
Physical Damage Truck Insurance
Trailer Interchange Insurance
Truck Liability Insurance
Motor Truck Cargo Insurance
Bobtail/Deadhead Coverage
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Certificate Request
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Insured Information
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Name
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Last
Garaging Address
Address Line 1
Address Line 2
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DBA
Mailing Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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Producer Information
Producer Information
Agency
Phone
*
Email
*
Producer
Fax
Are you the incumbent producer?
Yes
No
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Operation Information
Operation Information
Destination Cities
(Zone rated - 10% or more of operation)
Percentage of Loads Through Brokers
Cities Traveled Through
(Zone rated - 10% or more of operation)
Cities Traveled Through (copy)
(Zone rated - 10% or more of operation)
# Power Unites Current Year
Past Year Mileage
1st Prior
Projected
Gross Revenue Past Year
FMCSA/ICC Docket #
Projected
DOT #
Layout
Years Insured Under this Name:
Canceled or Non-Renewed in Past 3 Years
Yes
No
Owner Social Security Number (SSN)
If Yes, Reason
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Driver Information
Driver #1
Name
*
Hire Date
______________
License
Years Experience
______________
State
Layout (copy)
Driver #2
Name
Hire Date
______________
License
Years Experience
______________
State
Layout (copy) (copy)
Driver #3
Name
Hire Date
______________
License
Years Experience
______________
State
Do you have more drivers?
*
Yes
No
If Yes, please provide the information below
(Name, License, State, Hire Date, Years Experience)
Vehicle Schedule
(Attach Schedule if desired)
File Upload
Click or drag a file to this area to upload.
Vehicle #1
Year
TRL Type
_________
Make
Value
_________
VIN
GVW
_________
TRK/TRAC
Radius
Vehicle #2
Year
TRL Type
_________
Make
Value
_________
VIN
GVW
_________
TRK/TRAC
Radius
Vehicle #3
Year
TRL Type
_________
Make
Value
_________
VIN
GVW
_________
TRK/TRAC
Radius
Do you have more vehicles?
*
Yes
No
If Yes, please provide the information below
(Year, Make, VIN, TRK/TRAC, TRL Type, Value, GVW, Radius)
Insurance Carrier Information
(past 3 years) If any losses attach a complete description or loss runs
File Upload
Click or drag a file to this area to upload.
Information #1
Polity Dates
No. of Claims
______________
Company
Amount Incurred
______________
No. Units Insured
Drive Name
Information #2
Polity Dates
No. of Claims
______________
Company
Amount Incurred
______________
No. Units Insured
Drive Name
Coverage & Limits
Liability
Primary
Non-tracking
Auto Liability Limit:
Personal Injury Protection:
Hired Auto Liability:
HCP Limit:
Physical Damage
Comp & Coll
Additional Coverages:
_____________
UM/UIM Limits:
Medical Payments:
Hired Car Physical:
No. of Days:
Ded:
OTC:
Cargo
Limit
Commodities:
Commodities 1
Commodities 2
Commodities 3
Ded:
% of Load
% of Load 1
% of Load 2
% of Load 3
Value Per Truckload
Layout
Average
Average Value 1
Average Value 2
Average Value 3
Maximum
Maximum Value 1
Maximum Value 2
Maximum Value 3
Layout
General Liability
No. of Owners/Officers:
Limit:
No. of Employees
Payroll for other than owners, officers & clerical to include dispatches & mechanics:
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