Truckers Quote Form

TRUCKING INSURANCE
Company Name
Owner

First NameMiddle NameLast Name
Phone Number
E-mail
D.O.B.

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Garaging Address (Leave blank if same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
DOT
MC Number
Experience?
Own or Lease Tractor/Trailers?
Please remember to click Save/Add to add driver, vehicle and trailer information to the form. We will not receive the information if the Save/Add button is not selected.
List Drivers
Vehicle Information
Trailer Information
Electronic Logs? If yes, please list company
Dashcams?
Business Operations
Business Type
If Other, please enter below
EIN #
Other Business Type
Year Established
Business Operations & Description of Cargo
Please be as specific as possible on the cargo being hauled. If "General Freight" please copy the example & use specifics with %'s.
Radius of Operations
Do you cross state lines?
Do you haul hazardous material
Do you operate on a regular route?
Do you rent/lease your vehicles to others?
Type of Insurance Requested
Currently Insured?
Which company?
Please submit any and all Declaration pages/Loss Runs/Logs/MVR's to tanner@lighthouseinsures.com
Desired Deductible
Cargo Coverage?
If Yes, please enter amount of coverage below.
Coverage Amount
Do you need a General Liability Policy?
Do you need trailer interchange coverage?
Covers the trailer that is not owned by trucker, but being used under a trailer interchange agreement.
Physical Damage coverage?
Select Comprehensive Deductible
Select Collision Deductible
Do you need workers comp?
Select Desired Limit
Please enter Desired Limit
When would you like this policy to start?

MonthDayYear
Date
Lighthouse Insurance

2915 Bluestem Ln

Murfreesboro, TN 37128

Tanner@lighthouseinsures.com

Cell: 256-863-0617
Office: 629-238-0441
Should be Empty:

Business Operations

Type of Insurance Requested