Commercial Trucking/Auto Quote
Customer Details:
Company Name
*
DOT Number
*
If no DOT#, enter 000000.
Company EIN Number
Owner
*
First Name
Last Name
D.O.B.
*
MM/DD/YYYY
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Owner Driver's License # & State
*
Ex: W55509201 Florida or FL
Is Owner also a driver on the policy?
*
Yes
No
Does Owner have a CDL license?
*
Yes
No
Year the business was established?
Contact Person
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Garaging Address (leave blank if same as above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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List Drivers
Driver #1
Driver's Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Yes
No
Year obtained
YYYY
License # & State
Ex: W55509201 Florida or FL
Would you like to add more drivers?
Yes
No
Driver #2
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Yes
No
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Would you like to add more drivers?
Yes
No
Driver #3
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Yes
No
Year license obtained
YYYY
License # & State
Ex: W55509201 Florida or FL
Driver #4
Full Name
First & Last name
D.O.B.
MM-DD-YYYY
Years of experience
Does driver have a CDL?
Yes
No
Year license obtained
YYYY
License # & Sate
Ex: W55509201 Florida or FL
Vehicle Information
Vehicle # 1
Would you like to add another vehicle?
Yes
No
Vehicle # 2
Would you like to add another vehicle?
Yes
No
Vehicle # 3
Would you like to add another vehicle?
Yes
No
Vehicle # 4
Trailer Information
Trailer # 1
Would you like to add another trailer?
Yes
No
Trailer # 2
Would you like to add another trailer?
Yes
No
Trailer # 3
Would you like to add another trailer?
Yes
No
Trailer # 4
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Does owner or driver have any tickets or accidents in the past 5 years? If so, please include the violations and dates.
Electronic Log Device (ELD)? If yes, please list company.
Description of Operations
Business Type
*
Please Select
Individual / Sole proprietor
Partnership
Corporation
LLC
Other
Does your business require Federal filings with FMCSA, if so please enter your MC Number?
If you have an MC number / Operating Authority with FMCSA, you will be required to have Federal filings. If not need enter No or n/a
Radius of Operations
Please Select
0-99 miles
100-299 miles
300-499 miles
500+ miles
If tow truck, do you do repos?
Yes
No
Do you cross state lines when operating your business?
*
Yes
No
Do you haul hazardous material?
*
Yes
No
Do you rent/lease your vehicles to others?
*
Yes
No
Types of commodities hauled: (please select at least 4 commodities)
*
General Freight
Household Goods (moving/installing furniture)
Metal: sheets, coils, rolls
Motor Vehicles
Logs, poles, beams, lumber
Building materials
Mobile Homes
Machinery, Large objects
Fresh Produce
Liquids/ gases
Intermodal Cont.
Passengers
Oilfield Equipment
Livestock
Grain, feed, Hay
Coal
Meat
Garbage
US Mail
Dept. Store Products
Commodities dry bulk
Refrigerated food
Beverages
Paper/ Plastic Products
Agricultural/ Farm supplies
Construction
Other
If 'other' selected, please list:
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Type of Insurance Requested
Do you currently have a commercial auto policy?
Yes
No
Select the coverages needed
*
Primary Auto Liability
Truckers General Liability
Motor Truck Cargo
Physical Damage (Comp & Collission)
Roadside Assistance
Workers Compensation
NonTrucking Liability "Bobtail"
Auto Liability Limit (Choose the required coverage option).
*
$100,000
$300,000
$500,000
$750,000
$1,000,000
Other
General Liability Limit (Choose the required coverage option).
*
$1,000,000/ $1,000,000
$1,000,000/ $2,000,000
None
Motor Truck Cargo (Choose the required coverage option).
*
$100,000
$150,000
$200,000
$250,000
$250,000 or more
None
Desired Deductible?
*
$1,000
$2,500
$5,000
Do you currently have a personal auto policy? (10-20% Discount may apply)
Yes
No
How did you hear about us?
Please Select
Facebook/Instagram
Google
Family/Friend
Magazine
Email
Other
Submit
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