Truckers Questionnaire

- What is your DOT Number?
- Company Name
- Telephone Number
- Tax ID or EIN Number
- How did you hear about us?
- What is your email address
- How many years have you been in Business
- Confirm or provide your business address
  
  Line 1
  
  Line 2
  
  CityState
  
  Zip Code
- Are you trips typically over 500 miles each way
- Kindly confirm you need $1,000,000 in auto liability?
  
  YesNo
- Give 4 examples of items you haul
- Owner's full name
- Date of Birth
  
  MonthDayYear
- DL Issue Date
  
  MonthDayYear
- Driver's License Number
- Married?
- DL State
- Is that a Commercial Driver's License? How many years have you had the CDL?
- Owner's full name
- Date of Birth
  
  MonthDayYear
- Driver's License Number
- Driver's License State
- License Issue Date
  
  MonthDayYear
- Married?
- How many years have CDL (If Applicable)
- Truck 1 VIN# / Trailer 1 VIN#
- Truck 2 VIN# / Trailer 2 VIN#
- Is your vehicle financed
  
  YesNo
- Would you like your truck replaced if you have an accident?
  
  YesNo
- What's the value of the truck & Trailer
- Do you currently have Commercial Auto Insurance? How many years?
- Do you have an Electronic Logging Device (ELD)
  
  YesNo
- Do you need Cargo Coverage for $100,000?
  
  YesNo
- Do you need Refer Breakdown (N/A if trailer is not Refrigeratied aka Refer)
  
  YesNo
- Do you need any other coverages like General Liability?
  
  YesNo
- Additional Notes
  If customer has more vehicles and trailers, send them an email to reply with the additional information.
- How did you hear about us?
- Should be Empty: