Non-Trucking Automobile Liability & Vehicle Physical Damage Individual Application Application must be fully completed or coverage cannot be bound. Non-Trucking Liability YES NO Limit of NTL Date Quoted Effective Date Producer App Completed by Name of Vehicle Owner (Lessor) Tel# Address City State ZIP Motor Carrier Permanently Leased to (Lessee) Lease Effective Date US DOT MC # # Name of Lessee’s Primary Insurance Company Primary commodity hauled Radius of operation Unit # Year Make VIN GVW State of Stated Amount Registration 1. 2. 3. 4. 5. Owner/Operator (Lessor) Driver Name Yrs DOB DL# State Moving Accidents/ Expr Violations Losses 1. 2. 3. 4. 5. Lienholder Name Tel# Address City ZIP Loss History Policy Term Total Incurred From To Valuation # of # of Losses > Carrier Premium Date Claims $20,000 Mo. Yr. Yr.
Non-Trucking Automobile Liability & Vehicle Physical Damage Individual Application Application must be fully completed or coverage cannot be bound. Non-Trucking Liability YES NO Limit of NTL Date Quoted Effective Date Producer App Completed by Name of Vehicle Owner (Lessor) Tel# Address City State ZIP Motor Carrier Permanently Leased to (Lessee) Lease Effective Date US DOT # MC # Name of Lessee’s Primary Insurance Company Primary commodity hauled Radius of operation Unit # Year Make VIN GVW State of Registration Stated Amount 1. 2. 3. 4. 5. Owner/Operator (Lessor) Driver Name Yrs Expr DOB DL# State Moving Violations Accidents/ Losses 1. 2. 3. 4. 5. Lienholder Name Tel# Address City ZIP Loss History Policy Term From To Valuation Date Carrier # of Claims Total Incurred Premium # of Losses > $20,000 Mo. Yr. Yr.
AvantBrokerage-Non-Fleet-NTL-PD-APP.docx