Truck Owners Association Physical Damage Benefit Program This field is hidden when viewing the formBeneficiary countThis field is hidden when viewing the formAgent nameThis field is hidden when viewing the formAgent emailThis field is hidden when viewing the formAgent phoneThis field is hidden when viewing the formPDF logAgent information. Application filled by:Your name* First Last Your phone*Your email* Please enter agency National Producer Number (NPN) numberDoes customer have a DOT number?* Yes No Please enter DOT number* Account InfoThe customer would like to insure his vehicles as a(n):* Company. The coverage will be under company name. Example: Smith TruckingInc. Individual. The coverage will be under a person's name. Example: Joe Smith. Owner's Name on the Certificate*Owner's Name on the Certificate* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I'm also Doing Business As DBA Name*PhoneUpdated phoneCustomer's Email Address Coverage Effective DateCoverage Effective Date* MM slash DD slash YYYY Issue coverage today Coverage will be effective no earlier than 2 hours after signing the application* I clearly understand that coverage will be issued no earlier than 2 hours after signing the application Additional InformationGaraging Address* Same as mailing address Street Address ZIP Code Please cofirm that business and garaging State is* First Choice Drivers*All drivers must be listed as active TOA members. Click the "Add a Driver" button below, complete the required fields and then click the "Save" button. To make changes to an existing driver, click the "Edit" button or "Delete" button to delete the driver and start over. Coverages Name Date of Birth License State One or more drivers beneficiary has not been entered* I understand that any undefined beneficiary will be defined by law. Vehicles*In this section we will add vehicles to assign to the program. To do so, click the "Add a Vehicle" button below, complete the required fields and then click the "Save Vehicle" button. To make changes to an existing vehicle, click the "Edit" button or "Delete" button to delete the vehicle. Coverages Type Year Make VIN Stated Value (SV) Deductible Non-owned trailer I hereby certify that the vehicles listed abose will not be used hazardous* I hereby certify that the vehicles listed above will not be used to haul hazardous materials, coal or livestock, or used by loggers hauling out of logging camps, or used for public passenger livery or towing operations. I also certify that vehicles listed on the Application are not private passenger personal automobiles, taxi cabs, motorcycles, emergency vehicles or tow trucks. I hereby certify that all drivers who will operate the vehicles are listed in this Application and that all of the listed drivers meet TOA’s requirements for commercial driver experience. Upload additional files like MVR, loss run or lease agreement, if available Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, gif, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 10. Additional informationHas the client had Physical Damage Coverage in the last 3 years?* Yes No If no, the risk will be treated as a new entity.Quote Template Show me the Quote Template PDF Preview Claims ExperienceHas the client had Physical Damages Losses in last 3 years?* Yes, the client has had losses No Please enter the amount of paid losses including amount reserved: Year 2025*Please enter $ 0.00 if client had no losses in year 2025.Year 2024*Please enter $ 0.00 if client had no losses in year 2024.Year 2023*Please enter $ 0.00 if client had no losses in year 2023.Please check to confirm* I confirm that the customer's vehicle(s) does not have any damages and is not currently involved in any accidents. I confirm that the information I provided above is accurate. I confirm that the customer has been informed about possible changes in pricing or cancelation of coverage based on updated information. A company representative will contact the agency regarding any changes. Choose Vehicles for Non-Experienced Drivers*All non-experienced drivers must be chosen a vehicle. To make changes to an existing driver, click the "Edit" button. Driver name DOB Vehicle Thank you for applying for the Physical Damage Program. Once a quote is ready and you're ready to bind coverage, an initial payment will be required.This field is hidden when viewing the form(only for Employees)(only for Employees) Don't send any emails Output blank lienholders table Output blank ACH form ConfirmationPlease check to confirm* I confirm all information entered is correct. By clicking submit, your quote will be saved and assigned a quote number.
