Trucking Insurance Quote Request

1
How did you receive the link or hear about me?* This field is required.
2
Business Company Contact Name* This field is required.
First Name
Last Name
3
DOT# (If you do not have one, type 99999)* This field is required.
4
Is the DOT information on SAFER up to date?* This field is required.Click the link to verify: https://safer.fmcsa.dot.gov/CompanySnapshot.aspx
YESNO
5
Is the contact person listed also the business owner?* This field is required.
YESNO
6
If not, type the full name of the business owner below
7
Business Email * This field is required.
example@example.com
8
Business Phone Number* This field is required.
Please enter a valid phone number.
9
Primary Driver Information * This field is required.A driver is needed for the quote. It is okay if this is not the permanent driver; however pricing is based on driver experience and record.
First Name
Last Name
10
Attach a photo copy of driver's license for the primary driver below* This field is required.Additional driver info can be emailed or attached at the end of the form
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Original Year of CDL * This field is required.If NonCDL use 9999
12
Does this driver have ANY ownership in the company?* This field is required.We can extend an owners discount, if applicable.
YESNO
13
Does the primary driver own or lease the equipment in their personal name?* This field is required.
YESNO
14
Primary Vehicle Information* This field is required.Additional vehicle information can be emailed or attached at the end of the form
VIN or Year Make and Model
Value
Please Select
Please Select
Yes, Leased/Financed in Company Name
Yes, Leased/Financed in Owner's Name
Rental Unit
Unit does NOT have a leinholder or loss payee
Does the vehicle have a leinholder?
15
Vehicle Information (Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
16
Are FEDERAL filings required for this business?* This field is required.This means that you cross state lines (INTERSTATE) authority
YESNO
17
Business EIN * This field is required.
18
Are you the owner of the business?* This field is required.Name must appear under the certificate of formation (LLC paperwork)
YESNO
19
Do you have over 4 yrs of experience as a CDL driver?* This field is required.Suspended licenses within this timeframe are ineligible.
YESNO
20
Has this authority (DOT#) have over 3 years of insurance coverage?* This field is required.All insurance coverage must appear under the SAFER (licensing and insurance) tab
YESNO
21
Do you grant consent for Ladda Love Hawkins, agent with South Atlantic Insurance Services (www.satlanticins.com) to complete this quote request with the information provided.
Please Select
Please Select
Yes, please proceed
Yes, but I have additional questions. Please contact me first.
No, I have set an appointment and would like to meet before submitting the information for a quote.
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