Tow Quote- Detailed
Owner Name:
*
Owner Date of Birth:
*
Owner Driver's License number and state:
*
Contact Person and title:
*
Contact phone:
*
Contact email:
*
Company Name:
*
DBA If Applicable:
Office Phone #:
Email Address:
TDLR/Certificate #/VSF #:
*
Renewal Date:
How many drivers?
Do you need Worker's Comp coverage?
FEIN/SSN (EIN for the company):
Mailing Address:
*
Physical Address:
Do you do any repo towing?
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Do you require Wrongful Repo/Drive-away Coverage?
What limits are required? 300K, 500K, or 1 million?
*
Do you have a US DOT or MCDOT #? If yes, please list below:
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What type of towing do you perform? Consent/Incident Management/Private Property
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Do you have a telematic system? (Yes or No) If Yes, provide the name of the platform.
Current Premium (carriers WILL ask for this now):
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What combined single limit (CSL) do you require? 300,000/500,000/1,000,000
What on hook/cargo limit do you need? 25,000/50,000/100,000/200,000
Do you want UM coverage?
Do you want PIP coverage?
What are your gross sales per year?
What is your payroll per year?
Do you own a body shop, storage lot, mechanic shop, or used car lot?
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Is Garage Coverage needed?
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Is Commercial General Liability needed?
*
If yes, are you wanting a package or just the tow trucks?
How many years in business?
**Do you have a copy of your loss runs? We will need an UPDATED COPY for the last 5 years to submit a quote. They need to be dated within 60 days of your renewal date.
*
List of ALL Drivers:
Rows
Driver
Driver
Driver
Driver
Driver
Driver
Full Name:
DOB:
DL #:
Date of Hire:
Years of Experience:
List of ALL Drivers:
Rows
Driver
Driver
Driver
Driver
Driver
Driver
Full Name:
DOB:
DL #:
Date of Hire:
Years of Experience:
List of ALL Units (Carriers now cross-reference with TDLR):
Rows
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Year/Make/Model
VIN:
VALUE:
Body Type (flatbed/rollback, wrecker etc.):
Light/Med/Heavy
Continued list of Units:
Rows
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Tow Truck
Year/Make/Model
VIN:
VALUE:
Body Type:
Light/med/heavy
If ANY losses will show on your last 5 years of loss run reports, please include details for each loss (Carriers now ask for this information):
Other Notes:
Who filled out this form?
Please Select
Prospect/insured
Celeste
Paulina
Sabrina
Leonard
Jennifer
Mike
Submit
Should be Empty: