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Complete Quote Form
Complete Trucking Insurance Quote Form
Insured Information:
Business Name:
*
First
MC / DOT #
*
EIN #:
Business Owner Name
*
First
Cell:
*
Email:
*
Is the owner a company driver?
*
Yes
No
Business Owner Required Driver Information
*
DOB (MM/DD/YYY)
License #
State
CDL Exp.
Trucking Industry Exp.
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
No CDL
1
2
3
4
5
6
7
8
9
10+
No Exp.
1
2
3
4
5
6
7
8
9
10+
Business Information:
Business Information
*
Business Start Date (MM/YYYY)
Does Business have a DBA?
Entity Type
Filings Required?
Sole Proprietor
LLC
Inc./Corp
Other
NO
Federal
State
Federal & State
Business Physical Address:
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Mailing address vs Business Address
*
Is your mailing address the same as your business address?
Yes
No
Mailing Address (If different from physical address)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
TRUCK / TRAILER / EQUIPMENT INFORMATION:
Truck / Vehicle Information
*
Year
Make / Model
Type
Vehicle Value $
17 Digit VIN Number
Garaging Zip Code
Truck tractor
Box truck
Pickup truck
Cargo van
Delivery van
Dump truck
Auto hauler
Gas hauler
Flat bed
Reefer truck
Dry van
Garbage truck
Front loader
Tow truck
Car Carrier
Cement mixer
Tank truck
Other
Trailer / Scheduled Equipment Information
Year
Make
Model
Trailer Type
Trailer Value $
17 Digit VIN Number
Garaging Zip Code
For Trailers, please specify if Dry Van, Reefer, Flat Bed, etc., in the type field
Additional Interest
Last 4 of VIN #
Additional Interest Name
Street Address
City
State
Zip Code
Interest Type
Loss Payee
Additional Insured
Lien Holder
Leasing Agent
Other
Interest Type: Loss Payee, Additional Insured, Lien Holder, Leasing Agent
DRIVER INFORMATION:
Driver Information
*
First:*
Last:*
DOB MM/DD/YYYY:*
License #*
State*
CDL Exp:*
Date Hired (MM/YY)
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
No CDL
1
2
3
4
5
6
7
8
9
10+
Driver Related - Tickets or Accidents
*
Has ANY driver listed above had any violations or accidents within the last 3 years?
Yes
No
Yes to accidents or Tickets
*
Please list the Driver name and briefly describe the ticket received or accident that occurred, for each driver involved.
Business Operations Information:
*
Interstate or Intrastate
Travel Radius (Round Trip)
Average Load Weight?
Max Load Weight?
Interstate (more than 1)
Intrastate (One State)
100 miles
200 miles
300 miles
500 miles
Unlimited miles
Top 3 Commodities Hauled:
**Please select your top 3 Commodities Hauled from the drop downs
General Freight 1
General Freight 2
Consumer Goods
Building Supplies
Construction Mater.
Paper Products
Amazon
Plastic Goods
Amazon
Other
Plastic Products
Canned goods
Appliances
Office Equip
Amazon
Electrical Supplies
Stone Slabs
Plumbing Supplies
Other
Gravel & Rock
Sand
Asphalt
Cement
Other
Commodities Hauled Continued:
F & B (Refrig)
Machinery Equip.
Waste & Recycling
Household (Mover)
Auto Hauler
Frozen(not Seafood)
Seafood(Fresh)
Seafood(Frozen)
Construction Equip
Machinery
Other
Residential
Construction
Electronics
other
Yes
No
Yes
No
Commodities Hauled
*
Did you select "OTHER" in any of the above "Top 3 Commodities Hauled?"
Yes
No
goes w general freight
*
The underwriters will need a brief description of the "other" choices above. Please provide a brief description below.
PERSONAL AUTO INSURANCE INFORMATION:
*
Do you currently have an active personal or business auto policy?
Yes
No
Current Insurance
Current Carrier
Policy Expiration Date (MM/DD/YY)
Current Premium
PRIMARY INSURANCE COVERAGE REQUESTED:
*
Commercial Auto Liability*:
Auto Liability Ded.
Physical Damage
Motor Truck Cargo
Cargo Ded.
Trailer Interchange
Non-owned Trailer
$750 K
$1 million
Other (see comments)
$1000
$2500
Yes
No
$100k
$150k
$200k
$250k
None
Other (see comments)
$1000
$2500
$15K
$20K
$25K
$30K
$40K
$50K
None
$15K
$20K
$25K
$30K
$40K
$50K
None
Additional Insurance Coverage Requested:
Reefer
Occupational Accident
Workers Compensation
Hired / Non Owned Auto
Trailer Interchange
50 K
75 K
100 K
Other (see comments)
Yes
No
Yes
No
Yes
No
$15K
$20K
$25K
$30K
$40K
$50K
None
Does your company require General Liability Insurance?
*
Yes
No
GENERAL LIABILITY INFORMATION
*
Forecasted Revenue 12 months
Forecasted Payroll
Comments:
Upload a copy of the Driver’s licenses and current MVRs, and/or loss run information. (If available)
Drop files here or
Select files
Max. file size: 100 MB.
What Effective Date Would You Like for the Policy?:
*
MM slash DD slash YYYY
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Consent
The information you have provided is confidential and will be used by us to administer a response, document, or quote on your behalf. By submitting your data to us you agree to our storage and use of that data in this manner.
I agree to the Terms of Service.
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Email
This field is for validation purposes and should be left unchanged.
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