TOA - Physical Damage Program Quoting 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 byAgent Name* First Last Agent Phone*Agent Email* Please enter agency National Producer Number (NPN) numberDoes coverage holder have a DOT number?* Yes No Please enter DOT number* Account InfoCoverage Holder would like to insure their vehicles as:* 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 Coverage Holder 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 phoneCoverage Holder Email Address Coverage Effective DateCoverage Effective Date* MM slash DD slash YYYY Issue coverage today Coverage is not bound until customer service provides the agency with the Certificate of Insurance.* I understand and agree Location DetailsGaraging 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 "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 driver's 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 that, 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 MVR, loss run or lease agreement* 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 notes for UnderwritersPlease add information which can help us do a better quote for you.Has the client had Physical Damage Coverage in last 3 years?* Yes No If selected, risk will be treated as a new entity. Please look to quote working.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 2026*Please enter $ 0.00 if client had no losses in year 2026.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.Please check to confirm* I confirm that the coverage holder’s vehicle(s) are in service, and do not have any damages, and are not currently involved in any accidents. I confirm that the information I provided above is accurate. 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 Please review the PD Program quoting summary and click "SUBMIT FOR UNDERWRITING REVIEW" if ready to proceed.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 and shown above is correct. By clicking Submit, Quote number will be assigned to be able to print, send or bind the coverage.
