New Venture Insurance Form
We are glad you choose to be apart of this industry!
Owner's Name Company's Name
*
E-mail Address
*
example@example.com
Contact Number
Company's Physical Address
*
ex.) 2350 W 84th St Suite 9 Hialeah, FL 33028
USDOT or MC Number Tax-ID (EIN)
*
ex.) DOT: 0000000 MC: 0000000
ex.) 00-0000000
Does yourself or an employee currently have a CDL?
*
Yes
No
If you selected "Yes", please provide years of CDL.
What type of commodities does your company haul?
*
ex.) Dry Goods, Frozen Goods, Furniture, etc.
Hauling Hazardous Products?
*
Yes
No
What is your prefered hauling radius?
*
100-200 Miles
200- 300 Mile
300-400 Miles
400- 500 Miles
Unlimited Miles
Please select the Coverages you would like to obtain!
*
General Liability
Physical Damage
Motor Truck Cargo
Trailer Interchange
Other..
If you selected "Other", please let us know what coverages to go for!
Unit(s) Description
*
Driver(s) Description
*
Additional Information
We want to know specifically what YOU want!
Current Insurance Company
ex.) Progressive, Canal, National Indemnity
Give us a Target Premium!!
We truly want to search and find the best rates so we can beat your expectations!
By signing this form I authorize First Priority Insurance Group to use the information listed above in order to receive a trucking insurance quote
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