Truck Insurance Quick Quote Application
ARCERI & ASSOCIATES, INC
Company Name
*
Contact Name
*
E-mail
*
example@example.com
Phone #
*
504-555-9988
FEIN # or SS #
DOT #
Physical Address
City
State
Zip Code
Is the mailing address the same as the physical address?
Yes
No
Mailing Address
City
State
Zip Code
Yrs. Trucking Experience
*
Yrs. in Business
Yrs. CDL "A" License
New Venture (Under 2 yrs)
YES
NO
New Venture Questions
If you are a new venture, answering these questions is required.
Are you applying for DOT Authority?
YES
NO
Do you expect to increase the number of power units within one year?
YES
NO
If yes, how many units will you be adding?
Will you allow trip leasing?
YES
NO
Will you be using team drivers?
YES
NO
Does anyone ride with you?
YES
NO
What is your driver hiring process?
What is your Vehicle Maintenance Program?
What type of Dump Truck Business do you Operate?
Sand
Gravel
Dirt
Asphalt
Aggregate
Trash & Debris
Other
Scheduled Vehicles (Trucks/Tractors)
Truck Vehicle #1
Truck Vehicle #2
Truck Vehicle #3
Truck Vehicle #4
Truck Vehicle #5
If you have more than 5 Power Units, Upload a Complete Scheduled List Here. You can also Upload Copies of Registrations Here.
Browse Files
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Scheduled Vehicles (Trailers)
Trailer #1
Trailer #2
Trailer #3
Trailer #4
Trailer #5
If you have more than 5 Trailers, Upload a Complete Scheduled List Here. You can also Upload Copies of Registrations Here.
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Scheduled Drivers
Driver #1
Driver #2
Driver #3
Driver #4
Driver #5
If you have more than 5 Drivers Upload a Complete Scheduled List Here. You can also upload FRONT & BACK copies of Driver's Licenses Here.
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Auto Liab. Limit
*
$1 Million
$750,000
$500,000
$300,000
$100,000
Other
Gen. Liab. Limit
$1 Million
$750,000
$500,000
$300,000
$100,000
Other
Comp/Coll Ded.
$1,000
$2,500
$5,000
Other
Cargo Limit
$250,000
$100,000
Other
Has your insurance ever cancelled or non-renewed?
*
Yes
No
Other
If Yes, why?
What is your AVERAGE RADIUS of operation?
*
0 - 50 Miles
50- 150 Miles
150 - 300 Miles
300+ Miles
List SEVERAL CITIES where you may travel.
Who is your current Insurance Company?
What is your current Policy #?
Have you had any losses or claims in the last 5 years?
*
YES
NO
Upload a copy of Loss Runs Here. (If you don't have copies of Loss Runs, we will email you a Certified Statement of Loss Form to sign in the meantime)
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What is your Estimated Total Annual Premium ($) ?
For all your coverage
What is a Target Premium ($) ?
What would you like to pay?
Are you open to using driver usage-based TELEMATICS DEVICES to record miles driven, geo-location, driving behavior, etc in order to lower your premium? (NOT MANDATORY)
Yes
No
Are you open to using driver IN CAB CAMERAS in order to lower your premium? (NOT MANDATORY)
Yes
No
Are you open to using Liability Deductibles or (SIR's) Self-Insured Retentions in order to lower your premium? (NOT MANDATORY)
Yes
No
How did you hear about us?
Chris Arceri
Ruth Bush
Joel Overton
Postcard
Phone Call
Referred by friend/client
Google Search
Text Message
Email
What is your effective date of coverage?
*
-
Month
-
Day
Year
Date
ADD NOTES OR COMMENTS HERE.
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