Application for Commercial Auto Insurance with Cannabis Inventory Coverage
InsuranceType
IssuingCompany
Desired Effective Date of Policy
*
-
Month
-
Day
Year
General Information
Legal Business Name
*
DBA
Year Founded
*
FEIN / SSN
*
Authorized Contact
*
Authorized Contact Email
*
Authorized Contact Phone Number
*
Mailing Address
*
Garage Address
Does the business garage vehicles in additional locations?
Yes
No
Additional Location
Operation Radius (miles)
*
Nature of Business & Usage of Vehicles
*
Vehicle Schedule
*
Drivers Schedule
*
Requested Bodily Injury Limit ($)
Single-Deductible ($)
Please Select
$500
$1000
$2500
Deductibles ($)
Is Workers' Compensation provided for all employees?
*
Yes
No
Current Workers' Compensation carrier
Current Auto Insurance Carrier (if available)
Current Auto Policy Expiration Date (if available)
-
Month
-
Day
Year
Have you had any claims/losses in the past 3 years?
*
Yes
No
If 'Yes', please provide claims/losses details below.
Please provide last 3 years' loss runs report(s):
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Do you want to add coverage for your cannabis inventory via Motor Truck Cargo rider?
Yes
No
Cannabis Inventory Coverage
via a Motor Truck Cargo rider
Do motor carriers cross state lines?
*
Yes
No
Operator type
*
Owner of cargo
Cargo of others
Provide the Vehicles from the Schedule of Vehicles above that require inventory coverage.
*
Provide the Drivers from the Schedule of Drivers above that require inventory coverage.
*
Transport Frequency
*
Vehicle Protection
Are all vehicles equipped with fire extinguishers?
*
Yes
No
Are all vehicles equipped with locks?
*
Yes
No
Are all vehicles equipped with alarms?
*
Yes
No
Please verify that you are human
*
Print Name
*
Notes or Comments
Agent
Agent Name
*
Agency
Agent Email
Agent Office Phone
Agent Mobile Phone
Agent License No.
Agent Initials
Submit application
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