Auto Physical Damage Application

Complete each section, save whenever you need to pause, then review and electronically sign through InterSign.

APD-2026-000051

Status: In Progress

Your answers are private and can be saved before submission.

Applicant

Start with the US DOT number. We will retrieve available FMCSA information so you can verify it.

US DOT #

1. Name of Applicant:

Company

Doing business as

Year established

MC number

2. Address: Number / Street

Address line 2

City

State

Postal code

FEIN

Phone

Website

Is this a new venture?

Date insurance cover is required

Operations and coverage

Answer the proposal questions below. The source wording is retained.

3. Address of Principal Terminal if other than above:

City

State

ZIP

4. Radius of Operation:

Miles between following principal cities:

5. Type of Cargo carried:

6. Number of Years in this business:

7. Vehicle(s) legally owned by:

8. Name of previous Carrier:

9. Name of Carrier of Public Liability and Property Damage Insurance:

10. Has Applicant had previous Fire, Theft and Collision Automobile Insurance Cancelled?

If so, state date, name of Insurance Company and reason for cancellation:

11. Is Vehicle(s) Owner-Driven?

If drivers are employed, what investigations are made?

12. If more than one Vehicle covered, what is the estimated maximum possible terminal loss?

13. Amount of Deductible(s) on Collision:

14. Will you ever use hired equipment?

15. Will any of your Equipment ever be loaned or rented to others?

16. Do you own or use Trucks and/or Trailers other than those listed under Item 20 below?

If answer is "Yes" specify vehicles and state reasons why insurance is not required:

17. Is Equipment regularly inspected and serviced, if so, at what periods?

Inspection and service periods

18. Board Fire rate for terminal premises:

Loss payees and vehicles

7. Loss Payable to — add every loss payee, then complete Item 20 for every vehicle. Only the rows you enter appear on the PDF.

Loss Payable to

20. Description of Vehicle: (Specify Truck, Tractor, Trailer, Semi.)

Drivers

Add each driver. An MVR must be uploaded for every driver before the application can be sent for signature.

Loss history and supporting files

19. Premiums and Losses sustained by applicant last five years:

Supporting documents

Loss runs are required unless this is a new venture. An MVR is required for each driver. You may also upload miscellaneous documents.

Document type

Driver (required for MVR)

PDF, JPG, PNG, TIF or TIFF (20 MB maximum)

Description

Review and electronic signature

Save your latest answers. We will verify the required information and files before InterSign emails the applicant a secure signing invitation.

This application shall not be binding on the Underwriters unless and until a contract of insurance shall be issued and delivered in accordance herewith and then only as of the commencement date of said Insurance and in accordance with all terms thereof and the said Applicant hereby covenants and agrees to and with the Underwriters that the foregoing statements and answers are a just, full and true exposition of all the facts and circumstances with regard to the risk to be insured, insofar as same are known to the Applicant, and the same are hereby made the basis and condition of the Insurance.

SIGNED AT:

By (APPLICANT)

(Applicant should state official position)

Applicant email for InterSign

APPLICANT WITNESS:

Witness email

AGENT

Agent email

Location of Agency:

Source signature-date wording: “This day of 19”. InterSign adds the actual electronic signature date, signer identity, and audit evidence.

Save and resume

Anonymous applicants can receive a private resume link at the applicant email address. Issuing a new link invalidates the prior link.

Need Motor Truck Cargo coverage too?

The companion application reuses this applicant record while keeping its own questions, schedules, documents, and signature.

Start the Motor Truck Cargo application