Transportation Insurance Quote Application
Fill the fields below as accurately as you can and we will get back to you as soon as possible with trucking quotes.
Contact Information
Name
*
First Name
Last Name
Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail
*
Email
Phone Number
*
Format: (000) 000-0000.
Owner Driver License Number
*
Owner Date of Birth
*
Business Details
Business Legal Name(if applicable)
Company Name
Company DBA
Company Name
Business Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
EIN
Company Name
DOT Number
MC Number
Years in Business
*
Business Type
*
Sole Proprietor
LLC
Corporation
Other
Business Description
*
Business Description
Estimated Annual Revenue
*
Number of Employees(excluding owner)
*
Estimated Annual Payroll
Operations
Do you have independant contractors?
*
Please Select
Yes
No
If yes, how many?
Which services do you offer?
*
Furniture Delivery
Courier Services
Both
Other
Are you and your team licensed for all services provided?
Please Select
Yes
No
Vehicle Information
Do you own or rent delivery vehicles?
*
Please Select
Own
Rent
Both
Vehicle Details:
*
Rows
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6
Year
Make
Model
VIN
Driving Radius (in miles)
*
Number of Drivers/Contractors
Risk & Coverage
Do clients sign waivers or consent forms?
Please Select
Yes
No
Do you sell any retail products?
Please Select
Yes
No
Have you had any claims or complaints in the last 5 years?
*
Please Select
Yes
No
If yes, please briefly explain:
Has your prior insurance ever been cancelled or non-renewed by any insurer in the past 3 years (for any reasons NOT related to payment of premium)?
*
Yes
No
Additional Coverage Needs. Do you need coverage for:
Business Equipment
Business Interruption
Cyber Liability
Workers' Compensation
Document Uploads
Driver's License Photos of all Drivers and Owner License
*
Browse Files
Drag and drop files here
Choose a file
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of
Please upload your current commercial policy. Pricing is lower if you can show proof that you have prior coverage. If no commercial policy, please upload current personal policy.
Browse Files
Drag and drop files here
Choose a file
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of
Upload Insurance Requirements from Rental or Leasing Company on their company letterhead
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Service Details
What is your target policy pricing?
Do you have an ELD? If so which one?
Signature
*
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