Physical Damage Benefits Program

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Beneficiary count
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Agent name
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Agent email
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Agent phone
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PDF log
Agent information. Application filled by
Agent Name*
First Last
Agent Phone*
Agent Email*
Please enter agency National Producer Number (NPN) number
Does coverage holder have a DOT number?*
- Yes
- No
Please enter DOT number*

Account Info
Coverage 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.
Coverage Holder Name on the Certificate*
Coverage Holder Name on the Certificate*
First Last
Coverage Holder Mailing Address*
Street Address Address Line 2 City State ZIP Code
- I'm also Doing Business As
DBA Name*
Phone
Updated phone
Coverage Holder Email Address

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) Conestoga Deductible Non-owned trailer
Conestoga value will be added to unit value (quote(s) will show combined value of units and associated conestogas).
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 TOAâ€™s requirements for commercial driver experience.
Upload MVR, loss run or lease agreement*
Upload at least one MVR per driver, loss runs, and (for NTL quotes) a lease agreement for each driver
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, gif, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 10.
Additional notes for Underwriters
Please add information which can help us do a better quote for you.
Has the Coverage Holder had Physical Damage Coverage in last 3 years?*
- Yes
- No
Claims Experience
Has 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 information I provided above is accurate.

Physical Damage Benefits Program

Agent information. Application filled by

Account Info

Coverage Effective Date

Location Details

Claims Experience

Confirmation

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