UCR Filing Application Company Information Company name Street address City State -- Please Select --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Zip code Company DOT number Company MC number Contact Information Name of primary contact Phone number Email address Carrier Information What type of carrier? -- Please Select --PrivatePrivate and For-HireBrokerFor-HireFor-Hire and Exempt For-HireFreight ForwarderExempt For-HireLeased What participating state are you filing for? -- Please Select --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands What tax year is this UCR being filed for? -- Please Select --201920202021 Total number of vehicles or equipment? -- Please Select --0-2 - $115.003-5 - $226.006-20 - $401.0021-100 - $1,274.00 This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Δ Office HoursMonday: 8:00AM - 5:00PMTuesday: 8:00AM - 5:00PMWednesday: 8:00AM - 5:00PMThursday: 8:00AM - 5:00PMFriday: 8:00AM - 5:00PMThe Insurance Store offices are closed on weekends and most major holidays.
