A- Secure Transport Application

President/CEO Information


Vehicle 1

(Enter the total replacement cost for all permanently attached equipment. Permanently attached equipment means equipment and devices that are permanently installed or attached to your insured auto. Permanently attached equipment also includes)
(The current retail value of the vehicle excluding any permanently attached equipment. The easiest way to establish a current vehicle value is to consult a blue book publication. Other possibilities include consulting with a dealer/manufacturer or checking internet sites)

Additional Vehicle


(Drivers who have successfully completed knowledge and skill tests regarding the safe operation of commercial vehicles are issued a Commercial Driver’s License or CDL)
(Both at fault and not at fault and violations for the last 35 months, with description of accident or violation and approximate date)



Coverage Requested


I warrant the above to be true and understand the insurance contract will be considered based on my warranty.