PowerX Insurance & Financial Services Commercial Auto Quote Form
Fill the fields below to receive an accurate quote within 48 hours. The information collected will only be used by PowerX Insurance & Financial Services for the purposes of generating a quote. We will not sell your personal information to third parties.
Company Name
*
DBA Name
DBA Name
DOT #
If Applicable
MC #
If Applicable
FEIN #
If Applicable
Business Type
*
Please Select
LLC
C Corp
S Corp
Partnership
Sole Proprietorship
Other
Garaging Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner name
*
First Name
Last Name
Owner's DOB
*
 -
Month
 -
Day
Year
Phone Number
*
Format: (000) 000-0000.
E-Mail
*
Business Start Date
*
 -
Month
 -
Day
Year
Business Start Date
Desired Effective Date
 -
Month
 -
Day
Year
Date
Range of Operation
*
Intrastate
Interstate
Radius of Operation
*
Please Select
0-50
51-150
151-300
301-450
500+
Is there any related broker authority?
Yes
No
Annual Mileage
Business Type
Annual Revenue
*
Estimated Yearly Payroll
Federal or State Filings Required?
Federal
State
All vehicles owned, loaned, or leased?
*
Own
Loan
Lease
Major Cities?
*
Please list major cities where you will be operating
Has risk been cancelled or non-renewed in the last 3 years?
Yes
No
Services You are Interested In
*
Commercial Automobile Liability
Physical Damage
Cargo Liability
Bobtail or Non-Trucking Liability
General Liability
Worker's Compensation
BOP - Business Owner's Policy
Please provide a brief description of your business operations. What will you be hauling?
*
How many years of continuous coverage ?
*
Who are you currently insured with?
*
If Applicable
Driver Information
Driver 1
*
Driver 2
Driver 3
Add any additional drivers
If Applicable
Vehicle Information
Vehicle 1
*
Vehicle 2
Vehicle 3
Add any additional vehicles
If Applicable
Trailer Information
Trailer 1
Trailer 2
Add any additional trailers
If Applicable
Coverage & Limits
What are your preferred limits?
*
Did you speak with an agent before filling this form out?
Which agent did you talk to?
*
Tamelia
Armani
Jenny
Robert
Brittney
Orianna
Charlie
Day
Didn't speak to anyone
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