Truck Insurance Quick Quote Application

Truck Insurance Quick Quote Application

The 320 Firm
Select Your Agent
Company Name*
Desired Effective Date

MonthDayYear
Date
Best Contact Person if different than owner

First NameLast Name
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Owner's Name*

First NameLast Name
Owners Phone Number*
Please enter a valid phone number.
Owners Email*
example@example.com
DOT #
MC #
Electronic Logging Device Name
EIN # or SS #
Company Name & Address

Business Name

Street Address

CityState / Province

Postal / Zip Code
Is the mailing address the same as the garaging address?

YesNo
Garaging address if different than mailing address:
Yrs. in Business*
Yrs. CDL "A" License
New Venture (Under 2 yrs)

YesNo
Scheduled Vehicles (Trucks/Tractors)
Upload a copy of your Vehicle(s) Registration Here or Complete the Vehicle Info Below.

Cancelof
Truck Vehicle #1
ADD - 2ND TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #2
ADD - 3rd TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #3
ADD - 4th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #4
ADD - 5th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #5
ADD - 6th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #6
ADD - 7th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #7
ADD - 8th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #8
ADD - 9th TRUCK / TRACTOR / POWER UNIT

Yes
Truck Vehicle #9
Scheduled Vehicles (Trailers)
Upload a copy of your Trailer(s) Registration Here or Complete the Vehicle Info Below.

Cancelof
Trailer #1
ADD - 2ND TRAILER

Yes
Trailer #2
ADD - 3RD TRAILER

Yes
Trailer #3
ADD - 4TH TRAILER

Yes
Trailer #4
ADD - 5TH TRAILER

Yes
Trailer #5
ADD - 6TH TRAILER

Yes
Trailer #6
Scheduled Drivers
Upload Copies of the Driver's License for EACH Scheduled Driver or Complete the Info Below.

Cancelof
Driver #1
Add 2nd Driver

Yes
Driver #2
Add 3rd Driver

Yes
Driver #3
Add 4th Driver

Yes
Driver #4
Add 5th Driver

Yes
Driver #5
Driver #6
Add 7th Driver

Yes
Driver #7
Add 8th Driver

Yes
Driver #8
Add 9th Driver

Yes
Driver #9
Add 10th Driver

Yes
Driver #10
Coverage, Limits
File Upload

Cancelof
Select Auto Liability Limit

$1 Million$750,000$500,000$300,000Other
Select - Auto Liability Deductible (Discounts Available)

None$500$1000$2500$5000Other
Do you need an Additional Insured listed?

Additional Insured
Loss Payee? blanks Additional Insured? blank
If canceled or non-renewed explain:
Do you want Comprehensive & Collision (Full Coverage) Physical Damage on your Vehicles?

YesNo
Do you want Medical Payments?

YesNo
Do you want Uninsured Motorists?

YesNoIf yes, How much? ___________
Do you want Cargo Insurance?

YesNoIf yes, How much? ____________
Do you want Trailer Interchange?

YesNo
Do you want General Liability Coverage?

YesNoIf yes, How much? ____________
Towing & Motor Club

YesNo
Do you want a quote on Workers Comp?

YesNo
Do you want a quote for Occupational Accident?

YesNo
Radius, Mileage, Cities, Commodities
What is your AVERAGE Radius of Operation?

0-100 Miles100-300 Miles300-500 Miles500+ MilesOther
What are your Estimated Annual Miles Driven?
Commodities Hauled (Please List all Materials) e.g. Consumer Goods, Lumber, Frozen Goods etc...
What is the AVERAGE ($)VALUE of Commodity Hauled?
What is the MAXIMUM ($)VALUE of Commodity Hauled?
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1. Have you ever operated a trucking business under a different Authority or Name?

YesNo
2. Do you operate as a Freight Forwarder, Freight Broker or arrange loads for others under the same MC/DOT Numbers as the trucking authority?

YesNo
3. Do you own or use any equipment not scheduled on this application?

YesNo
4. Are loaded trailers ever left overnight, unattended or detached from power units?

YesNo
5. Have you ever filed for bankruptcy?

YesNo
This is a fill in the blanks field. Please add appropriate blank fields and text.
6. Do you ever haul oversized/overweight loads?

YesNo
7. Do you ever loan, lease or rent equipment to others?

YesNo
Explain any YES answers above/Gross Receipts from last year.
Insurance Information

(Please be specific)
Who is your current Insurance Company?
What is your current Policy #?
What is your Current Annual Premium ?
What is a Target Premium ($) ?
Has your insurance ever cancelled or non-renewed?

YesNo
Have you had any losses or claims in the last 5 years?

YesNoIf yes, What happened? __________________________________________________________________________________
Upload a copy of "LOSS RUNS" Here. (Current and any previous Insurance - Even if the policies were cancelled or short term coverage)

Cancelof
Discounts

Some carriers offer discounts for the following?
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)

YesNo
Are you open to using driver (Dual Facing) IN CAB CAMERAS in order to lower your premium? (not mandatory)

YesNo
Are you open to using (SIR's) Self-Insured Retentions or Deductibles on AUTO LIABILITY in order to lower your premium? (not mandatory)

YesNo
How did you hear about us?
ADD NOTES OR COMMENTS HERE.
Date

MonthDayYear
Date
Should be Empty:

Truck Insurance Quick Quote Application

Scheduled Vehicles (Trucks/Tractors)

Scheduled Vehicles (Trailers)

Scheduled Drivers

Coverage, Limits

Radius, Mileage, Cities, Commodities

Heading

Insurance Information

Discounts