Company

This field is for validation purposes and should be left unchanged.

General Information

Requested Effective Date(Required)

MM slash DD slash YYYY

This is the policy start date

Agent

Create Lead in AZ?

Yes

Contact Person(Required)

First Last

Contact Person Title:(Required)

Phone(Required)

Email(Required)

Business Name(Required)

Business uses a(Required)

FEIN

SSN

FEIN(Required)

SSN(Required)

Business Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Business Mailing Address(Required)

Same as Business Physical Address

Street Address Address Line 2 City State ZIP Code

Business Structure(Required)

Sole Proprietor

Partnership

Corporation

Other

Other Business Structure Type:(Required)

Is this a brand new business?(Required)

Yes

Year your business started?(Required)

Total Years of Piloting Experience(Required)

General Info - Current Insurance

Do you currently have pilot car insurance?(Required)

Yes

Do you have a separate personal auto policy?(Required)

Yes

Current Insurance Company(Required)

Current Auto Liability Limit(Required)

Current Premium(Required)

How many year have you had continuous insurance?(Required)

Do you want Professional and General Liability?(Required)

Yes

Do you require a written contract with your clients?(Required)

Yes

General Info - Estimate Revenue

Estimate revenue in the next 12 months:(Required)

Estimate revenue in the prior 12 months:(Required)

Enter "0" if you are a new venture

Coverage Selection

I want coverage for my equipment(Flags, Poles, Cones, Etc.)(Required)

Yes

Equipment Coverage Limit(Required)

$5,000

Radius (90% of the time)(Required)

Vehicles Schedule(Required)

VIN	Year	Make	Model	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Drivers Schedule(Required)

Driver Name	Drivers License #	Drivers License State	Has CDL?	Actions

There are no Drivers.

Maximum number of drivers reached.

Additional Info

Are any vehicles NOT solely owned and registered to you or you business name(Required)

Yes

Please Explain(Required)

Are you requesting coverage for an employee using their own vehicle in your opertation?(Required)

Yes

Do you rent or lease any of your vehicles to others?(Required)

Yes

If yes we will need a copy of the lease agreement.

Do you escort ONLY loads transporting hazardous material(Required)

Yes

Are any vehicles to be covered use only by family members?(Required)

Yes

Meaning they are NOT used for pilot car services at all.

Are any driver covered by Work Comp?(Required)

Yes

Do you permit non-employee passengers during trips?(Required)

Yes

Do you participate in an ride-sharing services such as Uber or Lyft?(Required)

Yes

Coverages for these services are NOT included in this policy!

List your primary states of operation(Required)

If you are OTR - Please put "Lower 48" otherwise please list your top 5-10 states

List any certifications you may have(Required)

List any safety devices you have(Required)

Examples: Voice Recorders, CB Radio, Dash Cameras, GPS Tracking, GPS Direction, Etc.

Please Select the Services Your Business Provides

Front Pilot Car(Required)

Yes

Years of Experience

% of of your total operation

Rear Pilot Car(Required)

Yes

Years of Experience

% of of your total operation

Flagging/Traffic Control(Required)

Yes

Years of Experience

% of of your total operation

High Pole(Required)

Yes

Years of Experience

% of of your total operation

Route Survey(Required)

Yes

Years of Experience

% of of your total operation

Rear Steering/Tillering(Required)

Yes

Years of Experience

% of of your total operation

Rigging/Securing Cargo(Required)

Yes

Years of Experience

% of of your total operation

Brokering/Subcontracting(Required)

Yes

Years of Experience

% of of your total operation

Hot Shot(Required)

Yes

Years of Experience

% of of your total operation

Total Operation Percentage(Required)

This should equal 100%

High Pole

Do you perform high pole work?(Required)

Yes

Please briefly explain the high pole work your perform:(Required)

Is your high pole equipment homemade or manufactured(Required)

Does your high pole use any compression fittings?(Required)

Yes

Briefly describe any training, experience, or safeguards used to prevent claims resulting from high pole work:(Required)

Route Survey

Are you contracted to perform route surveys?(Required)

Yes

Do you physically drive the route before producing a survey?(Required)

Yes

Do you charge a fee to perform route surveys?(Required)

Yes

Have you received any route survey education training?(Required)

Yes

Please Explain Training(Required)

Do you maintain files on how a survey was completed?(Required)

Yes

How long do you maintain the route survey files?(Required)

Do you provide a written guarantee for completed surveys?(Required)

Yes

Please Explain Written Guarentee(Required)

Does anyone else in your company perform route surveys?(Required)

Yes

Please explain who else performs route surveys(Required)

How many years of route survey experience does each person have?(Required)

Is there a pre-trip coordination and planning meeting?(Required)

Yes

Are permit/routing documents provided at these meetings?(Required)

Yes

Brokering/Subctonractors

Do you subcontract work with other drivers/Companies?(Required)

Yes

Annual revenue for subcontract or brokered work(Required)

Do they provide you with a copy of their current policy showing matching limits(Required)

Yes

All limits must match or exceed your limits including but no limited to Auto Liability, General Liability, and Professional Liability

Are you a certificate holder or additional insured on the subcontractor's insurance?(Required)

Yes

Are you paid a percentage of each brokered load?(Required)

Yes

What percentage(Required)

Commercial Auto(Required)

Yes

General Liability(Required)

Yes

Professional Liability(Required)

Yes

Auto Liability Limit(Required)

$1,000,000

$500,000

Uninsured/Underinsured Motorist B.I./P.D.(Required)

$1,000,000

$500,000

Medical Payments(Required)

Yes

General Liability(Required)

Yes

Professional Liability(Required)

$1,000,000

$500,000

$250,000

Bodily Injury/Property Damage Sublimit(Required)

$100,000(Inlcuded)

$250,000

$500,000

Auto Liability Limit(Required)

$1,000,000

$500,000

CAPTCHA

Pilot Car Insurance Quote

General Information

General Info - Current Insurance

General Info - Estimate Revenue

Coverage Selection

Additional Info

Please Select the Services Your Business Provides

High Pole

Route Survey

Brokering/Subctonractors

Nelson Insurance Agency

Get a Quote

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Pilot Car Insurance Quote

General Information

General Info - Current Insurance

General Info - Estimate Revenue

Coverage Selection

Additional Info

Please Select the Services Your Business Provides

High Pole

Route Survey

Brokering/Subctonractors

Nelson Insurance Agency

Get a Quote

Navigation

For Clients

Login

Don’t have an account?

Select an Option

Trucking Insurance Application

Fast Trucking Inquiry

Business Insurance Quote

Contractor Insurance Quote

Personal Insurance Quote

Trucking

Insurance

Application

Fast

Trucking

Inquiry

Business

Insurance Quote

Contractor

Insurance Quote

Personal

Insurance Quote