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Physical Damage Benefits Program

Truck Owners Association Physical Damage Benefit 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
Your name*
First Last
Your phone*
Your email*
Please enter agency National Producer Number (NPN) number
Does customer have a DOT number?*
- Yes
- No
Please enter DOT number*

Account Info
Customer would like to insure his 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
Mailing Address*
Street Address Address Line 2 City State ZIP Code
- I'm also Doing Business As
DBA Name*
Phone
Updated phone
Customer's Email Address

Coverage Effective Date
Coverage Effective Date*
MM slash DD slash YYYY
- Issue coverage today
Coverage will be effective not earlier than 2 hours after signing the application*
- I clearly understand that coverage will be issued not earlier than 2 hours after signing the application
Additional information
Garaging 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 drivers 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 TOAâ€™s requirements for commercial driver experience.
Upload additional files like MVR, loss run or lease agreement, if available
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 information
Please 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.
Quote Template
- Show me Quote Template
PDF Preview
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 2024*
Please enter $ 0.00 if client had no losses in year 2024.
Year 2023*
Please enter $ 0.00 if client had no losses in year 2023.
Year 2022*
Please enter $ 0.00 if client had no losses in year 2022.
Please check to confirm*
- I confirm that customer's vehicle(s) does not have any damages and is not currently involved in any accidents.
- I confirm that the information I provided above is accurate.
- I confirm that customer has been informed about possible changes in pricing or cancelation of my coverage based on updated information. Company representative will contact me regarding any changes.

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

Thank you for applying for the Physical Damage Program.

Based on the information you have provided, we are pleased to provide you with the price indication below.

Please review and confirm that all information entered is correct. In order to proceed to binding, an initial payment is required to bind coverage.
Price Indication PDF
Send email with price indication to client
- Send email with price indication to client
Client email to send quote price indication to*
Client name*
First Last
Client email*
Hidden
(only for Employees)
(only for Employees)
- Don't send any emails
- Output blank lienholders table
- Output blank ACH form
Confirmation
Please 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.

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