Independent Contractor Non-Trucking & Physical Damage Application Phone: (630) 472-2300 Fax: (630) 472-2385

Owner Name:	Requested Eff. Date:
Entity Name:	FEIN/SSN
Mailing Address:
City:	State:	Zip:
Phone #:	Fax #:
Entity Type	Corporation	LLC	Sole Proprietor	Partnership
CONTRACTED WITH:
***Please check requested coverage:
Non-Trucking Liability	Physical Damage
NTL Limit:	$ 1,000,000 CSL BI PD, $0 DED.	FTAC & Collision, Subject to Stated Limit
UM Limit:	$40,000 SINGLE LIMIT BI	Collision Deductible:	$1,000
***If Physical Damage Coverage is requested, it is the responsibility of the OWNER to assign the correct Insured Value and provide correct lien holder information.
Type of Equipment:
Extra Heavy Truck (Over 46,000 lbs. GVW)	Medium Truck (under 26,000 lbs. GVW)
Heavy Truck (26,000 lbs. GVW)	Cargo Van or Light Truck

Average Daily Radius of Operation:

Local (0-100 miles)	Intermediate (100-300 miles)	Long Haul (> 500 miles)

Vehicle Description
Year	Make	VIN	Insured Value
State	GVW	Commodities Hauled:

Name of Lien Holder Mailing Address

**Driver Information (List ALL Drivers, Report All Driver Changes Immediately)
Name	DOB	ST	License No.	SS#
1.
2.
Print Name:
Sign Name:	Date:

**A current (<60 days old) MVR is required for all Drivers. All Drivers must meet insurer requirements.