Step 1 of 3 33% Type Of Coverage* Physical Damage Non-Trucking Liability Excess Liability Name of Vehicle Owner* First Middle Last Business Street Address*Address Line 2City*State*AlabamaArizonaArkansasCaliforniaFloridaGeorgiaIowaIllinoisKentuckyMichiganMississippiMissouriNorth CarolinaNorth DakotaNew JerseyNevadaOhioOklahomaOregonPennsylvaniaSouth CarolinaTennesseeTexasUtahVirginiaWashingtonZip Code*Phone*FaxEmail* # Yrs as Driver*# Yrs Owner Operator*# Yrs in Business*Federal Tax IDRequired if requesting insurance under your business name.Social Security Number (SSN)If requesting insurance under your own name rather than a company name, we need your Social Security Number.Type of Business Entity*IndividualCorpPartnershipLLCDOT #*Motor Carrier Permanently Leased To*Radius of Operation*0-100 mi100-300 mi300-500 miOver 500 miCommodity Hauled*Do You Operate Under Your Own Authority?*YesNoSigned Copy of Independent Contractors Lease AgreementAccepted file types: pdf, jpg, png.Maximum Upload Size is 6MB. To attach the file, click "browse" or "choose" and navigate to the folder where you saved the image or document. Select the image or document(s) and click "Open" or "Select." Vehicle InformationYear*Make*Model*VIN #*State of Registration*Amount of Insurance Requested*Name of Driver, Unit #1* First Middle Last DL # and State*Upload Driver's License, Front & Back* Drop files here or Accepted file types: pdf, jpg, png. Upload images of the front and back of the driver's license in PDF, JPG, or PNG format. Scan or take a photograph of the front and rear of your driver's license then attach it to form. To attach the file, click "Select files" and navigate to the folder where you saved the image or document. Select the image or document(s) and click "Open" or "Select."# Years as a Driver*Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver #1 Home Phone*Driver #1 Cell PhoneI Have Additional Vehicles I'd Like to Insure*If you have additional vehicles you'd like included on an insurance quote, please select "Yes" and one of our customer service representatives will contact you to gather information on all vehicles.YesNo Terms & ConditionsRead the Terms and Conditions*FRAUD WARNINGS To All Prospective Insureds: Any person who knowingly, and with intent to defraud any insurance company or other person, les an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties in many states. To Prospective Insureds in: Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, nes, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or bene t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes and con nement in prison." Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, les a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. (Note: In OK the language must appear on the face of the policy in 10 pt. font or larger). Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or bene t or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to nes and con nement in prison. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. New York (Fire insurance applications): Any person who knowingly and with intent to defraud any insurance company or other person les an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured af rms that the foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy. New York (Automobile): Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the value of the subject motor vehicle or stated claim for each violation.” Pennsylvania (Automobile): Any person who knowingly and with intent to injure or defraud any insurer les an application or claim containing any false, incomplete or misleading information, shall, upon conviction, be subject to imprisonment for up to seven (7) years and the payment of a ne of up to $15,000. IMPORTANT – PLEASE NOTE for Non-Trucking Automobile Liability: This coverage is issued based on a warranty by the vehicle owner (lessor) that the insured tractor is permanently leased to the governmentally regulated motor carrier named on this application. All coverage expires when the permanent lease has been broken, cancelled, or terminated by either the contractor or motor carrier. A new certificate must be issued by ENGS Insurance Agency LLC each time the insured changes governmentally regulated motor carriers. All losses must be reported directly to Avant Specialty Claims by telephone, by the vehicle owner (lessor) or insured driver at 1- 800-542-2441. No permanent lease with a governmentally regulated motor carrier, no coverage, no exceptions. Any amounts paid by you for insurance coverage or services are due and owing solely to ENGS Insurance Agency, LLC, and any such amounts paid to Engs Insurance Agency for insurance coverage, services or otherwise shall not in any way reduce, impact or setoff any amounts due and owing by You to ENGS Commercial Finance Co., or eliminate or abrogate any obligations You have to ENGS Commercial Finance Co., whether under any nancing agreement, lease or otherwise. At our option and in our sole discretion, we may apply any payment received from you, not otherwise identi ed for a speci c purpose, either to pay for insurance coverage or services, or to pay for any Lease Payment or Installment Payment or to pay any other amount due and owing by You to ENGS Insurance Agency, LLC or ENGS Commercial Finance Co. The undersigned individual(s) certi es the following: (1) the information provided in connection with this application is true and accurate and has been submitted to obtain commercial insurance; (2) Engs Insurance Agency LLC (“EIA”) and Engs Commercial Finance Co. (“ECF”) is authorized to investigate and verify any information provided and to make inquiry of references, other creditors or lessors as to credit worthiness; (3) applicant(s), driver(s), guarantor(s), owners, principals named above, (hereafter referred to as “Customer”) and/or any individual whose name appears on the application explicitly authorizes any consumer reporting agency, motor vehicle reporting service and other individuals to provide credit or driving information to EIA and its subsidiaries and af liates or any of its insurance agents or carriers for use in connection with underwriting or issuing insurance. EIA, its subsidiaries and af liates, its insuring partners and joint users of such information are authorized to receive, exchange and to update such credit or driving information as appropriate during the term of the transaction. EIA will require proof of identity as required under the USA Patriot Act. I hereby consent to receive telephone, cell phone, e-mail or faxed communications from EIA. You hereby authorize us to share your information for marketing purposes. You must provide us written noti cation that you do not want us to share your information (except transactional or experience information). Please direct your request to ECF ATTN: Chief Risk Of cer, at credit@engs nance.com. Please include a copy of your driver’s license. By selecting the checkbox below, you are confirming that you have read the terms and conditions outlined above. I have read and agree to the terms and conditions above Electronic Signature Agreement*By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that your use of a key pad, mouse or other device to type your name constitutes your signature as if actually signed by you in writing. I Accept APPLICANT CONSENT: By submitting this application, the submitting individual(s)certifies the following: (1) the information provided in connection with this application is true and accurate and has been submitted to obtain commercial credit; (2) Dealer , Engs Commercial Finance Co. (“ECF”), and any affiliates of ECF, jointly or separately, are authorized to investigate and verify any information provided and to make inquiry of references, other creditors or lessors as to credit worthiness; (3) applicant(s), guarantor(s), owners, principals, named above, and/or any individual whose name appears on the application explicitly authorizes any consumer reporting agency and other individuals to provide credit information to Dealer, ECF and any affiliate of ECF for use in connection with the transaction; and (4) the individual submitting this application is duly authorized to execute and submit this application. The applicant expressly authorizes any references listed in the application to release requested credit, financial and business information for use in connection with the transaction. Dealer, ECF, any affiliates of ECF and joint users of such information are authorized to receive, exchange and to update such credit information for so long as needed for these purposes. ECF or its affiliates may contact the applicant and transmit information electronically (including email, text and instant messages) at any email address or telephone number (including a wireless telephone number) provided.