Truckers Questionnaire

Business Information/Contact Details
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

Operational Questions
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

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Owner's Information
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?

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Additional Driver Information
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)

Vehicle year make and model
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

Other Questions FOR DISCOUNTS
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?
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