Trucking Quote Request Form

1
First off, please enter your business address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
2
Next, what is your name?* This field is required.
First Name
Last Name
3
Thanks, {nextWhat:first}. And what is the name of the trucking business you're reaching out about?* This field is required.
4
Is {bizname} an existing business or a start-up?* This field is required.
Existing
Start-up
5
How soon do you plan to be in business?* This field is required.
As soon as possible!
Within 2-3 months
Not sure
Just researching insurance costs
6
How many years old is {bizname}?* This field is required.
7
Do you have an active DOT number?* This field is required.
Yes
No
In progress
8
Please enter your DOT number for {bizname}* This field is required.
9
What type of insurance do you need for {bizname}?* This field is required.Check as many as apply
Auto liability
Commercial property
General liability
Cargo
Bobtail
Physical damage
Umbrella & excess liability
I'm not sure what all I need
Other
10
Is this for a hotshot trucking business?
Yes
No
11
What kind of trucking does {bizname} do?* This field is required.Check all that apply
Agriculture
Aggregate hauling
General freight
Hotshot
Logging
Reefer
Other/combination
Other
12
What kind of trucking business is {bizname}?
Agriculture
Aggregate hauling
General freight
Hotshot
Logging
Reefer
Other/combination
13
In a sentence or two, please describe the operations of your business. If you're a start-up, please give your background/experience in trucking.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
What's your typical radius of operation? (most of the time)* This field is required.
250 miles or less
250 to 500 miles
500 to 1000 miles
Greater than 1000 miles
15
Estimated gross annual revenue (if a start-up, enter your best guess)* This field is required.
less than $50,000
$50,000 to $500,000
$500,000 to $1M
$1M to $3M
$3M to $5M
$5M to $10M
$10M or more
16
Do you need insurance filings?* This field is required.
Yes
No
Not sure....
17
Do you currently have insurance in place?* This field is required.
YESNO
18
What is the ballpark range of your current insurance annual premium?* This field is required.If you don't have insurance yet, enter what you expect it to be
$10k or less
$10k to $25k
$25k to $100k
$100k or more
19
Ok {nextWhat:first}, few more questions about your current insurance. If you have your declarations page handy, you can simply upload that now and it'll streamline the process. Or you can answer a few questions manually.* This field is required.Gathering this info now helps us get you an accurate quote and we can spot ways to save you money.
I'll upload my declarations page
I'll enter the info manually
20
Ok great, please upload the declarations page now.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
Ok no problem. First question - who is your current insurance carrier?* This field is required.
22
How many years have you been with your current insurance carrier?* This field is required.
23
Any claims filed within the past 3 years?* This field is required.
YESNO
24
Not a problem. We need some details on the claim(s) to get you an accurate quote. Do you want to upload your loss history report or manually input info?* This field is required.
I'll upload the report
I'll enter info manually
25
Upload your loss history report below
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Ok sure. Please give a brief summary of the claim(s)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
How soon is your insurance up for renewal?* This field is required.
30 days or less
Within the next few months
6 months out
Other
28
What limit of motor truck cargo coverage do you carry?* This field is required.
less than $50k
$50k to $100k
$100k to $250k
Beyond $250k
Other
29
Next, we need to gather info on your vehicles and equipment. Would you like to upload a schedule of these items or enter manually?* This field is required.Please note: if you are buying a vehicle, but haven't settled on one yet, just enter info for an example of what you expect to purchase.
Upload
Enter manually
30
Great! Please upload the document(s) below
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
31
Please list out your equipment/vehicles. Include the following: Year - Make - Model - Value - VIN (if applicable) **Include trailers here as well, not just trucks*** This field is required.Please note: if you are buying a vehicle, but haven't settled on one yet, just enter info for an example of what you expect to purchase.
Huge
Large
Normal
Small
Ok
Ok
32
Next, we need drivers' info. Upload a schedule or enter manually?* This field is required.
Upload
Enter manually
33
Upload the drivers' schedule now
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
34
Ok great. Please list out all drivers and include the following (to the best of your ability) - 1) Name 2) Date of birth 3) License number & state* This field is required.tip: if on a computer, start a new line by pressing "enter" while holding down the "shift" key
Huge
Large
Normal
Small
Ok
Ok
35
What's your best email address we can send your quote to?* This field is required.
example@example.com
36
And your phone number?* This field is required.
Please enter a valid phone number.
37
You're practically done, {nextWhat:first}! Just two more simple questions. First, what's got you looking for insurance today?* This field is required.
Start-up
Vehicle/equipment/property purchase
Cost savings
Not sure I'm properly covered
Frustrated with my current insurance agent or carrier
Other
38
And lastly, regarding the stage of the insurance process, check all that apply.* This field is required.
I've gotten other quotes already
I'm waiting on call backs for other quotes
My current agent is shopping out for me
This is the first quote I've gotten
Other
39
submission counter
40
Agent Email
example@example.com
Should be Empty: