ADM-1003 (4-16)
P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
849 West Levoy Dr., Suite 230, Taylorsville, UT 84123
(801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (800) 332-9285
COMMERCIAL DRIVER EMPLOYMENT HISTORY
(Truckers)
Insured Name: Policy No.:
Driver Name: Date of Birth: License Number:
Total Yrs. Experience: Date Comm'l Lic. Obtained: VIN of unit owned:
Experience listed should be for the same type of equipment you will be driving on this policy. The Commercial License
obtained date should be the date of license for the same type of equipment.
Including Current Employer, list in order of most recent employer first. MUST HAVE FULL TWO YEARS.
Employer: MC/DOT No.: Phone:
Address:
Amount of Experience: Straight Truck % Tractor/Semi Trailer % Dump Truck %
Driving Vehicle Types Listed: Log Truck % Service Vehicle % Other %
Type of Driving: For-Hire Private Carrier Farm Passenger Other
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Employer: MC/DOT No.: Phone:
Address:
Amount of Experience: Straight Truck % Tractor/Semi Trailer % Dump Truck %
Driving Vehicle Types Listed: Log Truck % Service Vehicle % Other %
Type of Driving: For-Hire Private Carrier Farm Passenger Other
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Employer: MC/DOT No.: Phone:
Address:
Amount of Experience: Straight Truck % Tractor/Semi Trailer % Dump Truck %
Driving Vehicle Types Listed: Log Truck % Service Vehicle % Other %
Type of Driving: For-Hire Private Carrier Farm Passenger Other
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Have you had any accidents in the last three years? ........................................................................................ Yes No
If yes, please describe:
During the past three years, have you had at least two years over-the-road driving experience with equip-
ment similar to that which you will be operating for this employer? ...................................................................
Yes No
The undersigned applicant represents that the information provided herein is true and correct. I further understand that by
applying for insurance, I authorize Nationwide Insurance to verify the information provided above.
Signature of the Named Insured or Driver Date
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signature
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