Commercial Insurance Quotation Form

1
Name* This field is required.
Mr.
Mr.
Ms.
Mrs.
Mx.
Prefix
First Name
Middle Name
Last Name
Suffix
2
Personal Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
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
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number* This field is required.
Area Code
Phone Number
4
E-mail
example@example.com
5
Owner's Driver's License Number* This field is required.
6
Owner Date of Birth* This field is required.
7
Driver's License Name (as it appears on your license)* This field is required.
8
Company Name (if Sole Prop, List Your Name, Sole Prop)* This field is required.
9
How much time have you been operating the business in your name (years/months)* This field is required.
10
What is your annual gross sales? (Estimate if unknown)* This field is required.
11
Company Address
Street Address
Street Address Line 2
City
Please Select
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
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Date Business Started* This field is required.
13
List All Business Owners* This field is required.
14
Garaging Address (Where You Will Park Your Truck)* This field is required.
Street Address
Street Address Line 2
City
Please Select
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
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Needed by Date of Quote* This field is required.
16
Effective Date of Policy* This field is required.
17
How many years of experience do you have?* This field is required.
18
Number Of Drivers* This field is required.
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
19
Driver First and Last Name* This field is required.
20
Driver Date of Birth* This field is required.
21
Driver CDL number* This field is required.
22
List the full name(s), date(s) of birth, CDL number(s), and state(s) for ALL OTHER DRIVERS THAT WILL OPERATE YOUR EQUIPMENT:* This field is required.
23
Have you had any (fault or not at fault) violations or accidents in the past 5 years? * This field is required.
Yes
No
24
How many liability claims have you had in the past 3 years?* This field is required.
25
List Details and Dates of ANY and ALL violations and/or accidents for ALL DRIVERS (both at fault and not at fault)e.g. car hit you, hitting an object, speeding, weather damage, vandalism, theft
26
Have any drivers completed an approved United States Armed Forces defensive driving course within the last 3 years?* This field is required.
Yes
No
27
Do any drivers require an SR22 Filing?* This field is required.An SR22 is a statement of financial responsibility that certain people are required to provide. An SR22 is proof a driver has the proper amount of insurance that his or her state has required him or her to have. Liability coverage must be present if a filing is required and the liability limits must be equal to or above the minimum liability limits of the filing state. The most common reasons people need an SR22 are because of a DUI or DWI, driving without insurance, or driving with a suspended license. Drivers requiring a filing cannot be excluded from coverage.
Yes
No
28
Will you be hauling for another motor carrier (hauling under someone else's authority)?* This field is required.
Yes
No
29
What is the name and USDOT# of the motor carrier for which you will be hauling? If you have your authority or your own USDOT number, write N/A.* This field is required.
30
Do you have a lease/haul agreement with a motor carrier?* This field is required.
Yes
No
31
Do you plan on applying for or having a USDOT number within 60 days?* This field is required.
Yes
No
32
What is your DOT #? (if none, type N/A)
33
Select Type of Trucking Company You Operate:* This field is required.
Please Select
Please Select
Agricultural
Auto Hauler
Coal
Containers
Debris Removal
Dirt, Sand and Gravel
Escort Vehicles
Expediters
Fracking, Sand or Water
Freight Forwarder
Garbage & Trash
General Freight/Other
Hazardous Materials/Placards
Hotshot Transport
Household Goods Mover
Livestock
Logging/Wood Chips
Machinery & Heavy Equipment
Mobile Home Toter
Oilfield Materiels
Refrigerated Goods
Scrap Metal/Scrap Auto
Steel
Other For-Hire Trucking
34
Number Of Vehicles* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
35
Number Of Trailers* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
36
What commodities will you be hauling? (select all that apply)* This field is required.
Please Select
General Freight
Building Materials
Refrigerated
Other
Agricultural Equipment
Alcoholic Beverages (except beer and one)
Appliances (except TV and stereos)
Arms, ammunition, fireworks
Automobile parts and accessories
Automobiles (5 vehicles or less)
Automobiles (6+ vehicles)
Beer and Wine
Dirt, Sand, Gravel
Beverages (non-alcoholic)
Building Materials
Bulk or Bagged Nuts
Cameras and Film
Cannabis, CBD
Canned Goods
Cement, Sand, Gravel
Chemicals
China and Ceramics
Cigarettes and Cigars
Clothing
Coal
Computers
Contractors Heavy Equipment
Cosmetics and Perfumes
Cotton
Courier Documents
Cranes
Currency
Dairy Products
Dangerous articles, explosives, corrosive, flammable
Department Store Goods
Documents
Drugs (except Narcotics)
Dry Goods
Eggs (Shell)
Electric Supplies and Fixtures
Empty Trailers
Farm Products
Fertilizer
Fine Arts
Food Products
Fracking
Frozen or Refrigerated
Furniture
Furs
General Merchandise
Glassware
Gray, Hay, Feed
Hanging Meat
Hardware and Paint
Hazmat
Household Goods (Residential Delivery)
Intermodal Containers
Jewelry
Ladies and Mens Dress Apparel
Leather Goods
Liquid Haulers (bulk nonflammable)
Livestock and Live Poultry
Logs
Lumber
Machinery (Light)
Machinery and Heavy Equipment
Meat
Metal and Steel
Mobile Homes
Narcotics
Non-Ferrous Metal
Nursery-Plants, Trees, Flower
Office Equipment
Paper and Paper Products
People
Petroleum Products (under 140 degrees flash point)
Pipe, Cable, and Wire
Plumbing Supplies
Plastic and Plastic Products
Poultry (Dressed)
Power Tools
Precious Metals
Produce
Recreational Vehicles, Boats, and RVs
Refuse, Garbage
Rugs and Carpet (Oriental)
Rugs and Carpets (Other than Oriental)
Scrap Metal
Seafood Canned
Seafood Fresh
Seafood Shellfish
Seafood
Shoes
Specialized Heavy Haulers
Sporting Goods and Toys
Textiles
Tires and Tubes
Tobacco
TV, Radios, and Stereo Equipment
Video Equipment and Tapes
37
Do any listed vehicles or the load require a hazardous material placard?* This field is required.
Yes
No
38
Radius Of Operation* This field is required.
Please Select
Please Select
Local....... 0-50 Miles
Intermediate 51-200 Miles
Regional.... 200-500 Miles
Long Hual... 500+ Miles
39
Do you operate outside of your state's borders? (interstate)* This field is required.
Yes
No
40
Do you need federal filings?* This field is required.
Yes
No
41
Do you operate inside your state's borders only? (intrastate)* This field is required.
Yes
No
42
Do you need state filings?* This field is required.
Yes
No
43
Will you be using an ELD? (Electronic Log Device)* This field is required.
Yes
No
44
Are You Currently Insured for a Personal Vehicle?* This field is required.
Yes
No
45
Are You Currently Insured for a Commercial Vehicle?* This field is required.
Yes
No
46
Have you had at least 1 year of continuous insurance coverage?* This field is required.
Yes
No
47
What is your current insurance policy expiration date?* This field is required.
48
How long have you had your own continuous commercial auto insurance coverage in your current business name? (if this does not apply to you, write N/A)* This field is required.
49
What is the total value of your vehicles?* This field is required.
50
What is the total value of your trailers?* This field is required.
51
What is your current bodily injury liability limit?* This field is required.
Please Select
Please Select
$300,000
$500,000
$750,000
$1,000,000
Other
52
What type of Non-Trucking Liability Coverage do you need?* This field is required.Non-Trucking Liability provides coverage to a SOMEONE ON PERMANENT LEASE TO A MOTOR CARRIER that supplies primary liability coverage. Non-Trucking Liability coverage applies only when the customer is using his or her scheduled auto for non-business, personal use (such as going to the movies, picking up groceries, attending sporting events, etc.). It can pay for medical and other expenses associated with injuries to others or damage to other peoples' property that the customer causes. Non-Trucking Liability coverage does not apply when the scheduled auto is being used to transport any goods or merchandise for hire, nor while goods or merchandise are being loaded or unloaded. Primary liability coverage must be maintained by the motor carrier to cover the customer while operating his or her vehicle in a trucking capacity on behalf of the motor carrier.
Please Select
Please Select
N/A
$300k CSL
$500k CSL
$750 CSL
$1 million CSL
53
What Bodily Injury and Property Damage Liability Will You Need?* This field is required.Bodily Injury and Property Damage Liability is often simply referred to as Auto Liability Insurance Cannot have if you have Non-Trucking/NTL. This is for someone that has their own authority. The average typical driver selects $1M CSL Limits are described as dollar limits "per person/per accident/property damage" or "CSL" (combined single limit). Bodily Injury Liability provides coverage if the you or your driver causes an accident that injures or kills another person and will pay for the related expenses. Bodily Injury will cover hospital and medical bills, rehabilitation, long-term nursing care, funeral expenses, lost earnings, pain and suffering, and other expenses, up to the limits selected. Property Damage provides coverage if you or your driver causes an accident that damages another person's property and will pay for the related expenses. Property Damage covers the expense to repair or replace damaged items, including other vehicles, lamp posts, houses or even a pet, up to the limits selected. You can choose liability limits as either Split Limits or a Combined Single Limit (CSL) if available. Split Limits divide bodily injury liability limits per person and per accident. The insurance carrier can provide up to the limit selected per person, but only up to the total limit selected per accident. For example: You choose liability coverage totaling $50,000 for bodily injury per person and $100,000 for bodily injury per accident (the maximum that the insurance carrier would pay out for bodily injury on a claim) and $50,000 for property damage liability. These are called "split limits" because the amounts are "split" per person and per accident. Ifyou have a claim and are liable for $25,000 of bodily injury costs to another person, the insurance carrier would pay the full cost because you would have up to $50,000 per person of bodily injury coverage. Combined Single Limit (CSL) combines the liability coverage into one total limit per accident. A CSL is stated as one number, such as: $100,000. For example: You choose liability coverage totaling $100,000. If you have a claim and are liable for $25,000 of bodily injury costs to another person and $50,000 of property damage, the insurance carrier would pay the full cost ($75,000) because you would have up to $100,000 of coverage.
Please Select
Please Select
$25k/$50k/$25k
$50k/$100k/$25k
$100k/$300k/$50k
$250k/$500k/$100k
$100k CSL
$300k CSL
$350k CSL
$500k CSL
$750k CSL
$1 million CSL
$1.5 million CSL
$2 million CSL
Other
54
Cargo Limit* This field is required.
Please Select
Please Select
$50,000
$100,000
$250,000
Other
55
What amount of Uninsured Motorist Bodily Injury Coverage would you like?* This field is required.Limits are described as dollar limits "per person/per accident" or "CSL" (combined single limit). Uninsured Motorist Bodily Injury provides coverage for damages which you are legally entitled to recover from another party who is considered at-fault for an accident but does not have insurance.
Please Select
Please Select
Not Selected
$25k/$50k
$50k/$100k
$100k/$300k
$250k/$500k
$100k CSL
$300k CSL
$350k CSL
$500k CSL
$750k CSL
$1 million CSL
56
What amount of Underinsured Motorist Bodily Injury Coverage would you like?* This field is required.Limits are described as dollar limits "per person/per accident" or "CSL" (combined single limit). Underinsured Motorist Bodily Injury provides coverage for damages which you are legally entitled to recover from another party who is considered "at fault" for an accident but does not have enough insurance.
Please Select
Please Select
Not Selected
$25k/$50k
$50k/$100k
$100k/$300k
$250k/$500k
$100k CSL
$300k CSL
$350k CSL
$500k CSL
$750k CSL
$1 million CSL
57
What amount of Personal Injury Protection (PIP) would you like?* This field is required.Personal Injury Protection (PIP) coverage provides payments for appropriate benefits if you or anyone else covered under the policy is injured in an accident. PIP has three components: • Medical Benefits: Coverage for the cost of your treatment from hospitals, doctors and other medical providers • Disability Benefits: Reimbursement for certain expenses that result from injuries, such as lost wages or any reasonable expenses incurred in obtaining services from others during a period of disability • Death Benefits: Benefits payable if an insured dies because of bodily injury sustained in an accident
Please Select
Please Select
Not Selected
$10k w/ $0 Deductible
$10k w/ $250 Deductible
$10k w/ $500 Deductible
$10k w/ $1,000 Deductible
$100k CSL
$300k CSL
$350k CSL
$500k CSL
$750k CSL
$1 million CSL
58
Which Deductible would you like for your Comprehensive Coverage for the vehicles?* This field is required.Comprehensive coverage protects your vehicle if it is damaged by something other than a collision with a vehicle or object (such as hail or a falling tree), or if your vehicle is stolen. Comprehensive also covers damages from a collision with an animal.
Please Select
Please Select
Not Selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
59
Which Deductible would you like for your Collision Coverage for the vehicles?* This field is required.Collision coverage protects your vehicle if it is damaged in an accident. It pays to repair or replace the vehicle if it collides with another object, overturns, or rolls. Collision coverage must be purchased with Comprehensive or Fire & Theft with Combined Additional Coverages.
Please Select
Please Select
Not Selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
60
Which Medical Payment Coverage would you like? * This field is required.Medical Payments coverage pays certain medical and funeral expenses you and any passengers in your vehicle who are injured during an accident or auto-related injury. This coverage is only available on power units. Collision coverage must be purchased with Comprehensive or Fire & Theft with Combined Additional Coverages.
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Please Select
Not Selected
$500 per person
$1,000 per person
$2,000 per person
$5,000 per person
61
Which Rental Reimbursement Coverage would you like? * This field is required.Rental Reimbursement provides coverage for rental car costs to temporarily replace your vehicle due to a covered loss. Please review the policy contract for complete coverage information. Rental Reimbursement may be purchased for any vehicle covered by Comprehensive or Fire & Theft and Collision coverage.
Please Select
Please Select
Not Selected
$30 per day, $900 max
$40 per day, $1,200 max
$50 per day, $1,500 max
$70 per day, $2,100 max
$80 per day, $2,400 max
$90 per day, $2,700 max
$100 per day, $3,000 max
$125 per day, $3,750 max
$150 per day, $4,500 max
$175 per day, $5,250 max
$200 per day, $6,000 max
$250 per day, $7,500 max
$300 per day, $9,000 max
62
Which Rental with Downtime Coverage would you like? * This field is required.Downtime / Rental provides coverage for rental car costs to temporarily replace your vehicle due to a covered loss. The insurance carrier will provide assistance in locating a reasonable replacement to keep your business operating. If the carrier cannot locate a reasonable replacement vehicle they will pay for downtime.
Please Select
Please Select
Not Selected
$40 per day, $1,200 max
$50 per day, $1,500 max
$70 per day, $12,100 max
$80 per day, $2,400 max
$90 per day, $2,700 max
$100 per day, $3,000 max
$125 per day, $3,750 max
$150 per day, $4,500 max
$175 per day, $5,250 max
$200 per day, $6,000 max
$250 per day, $7,500 max
$300 per day, $9,000 max
$500 per day, $15,000 max
63
Which Roadside Assistance Coverage would you like? * This field is required.Roadside Assistance coverage provides towing to the nearest qualified repair facility and covers a specified amount of the necessary labor at the place of breakdown when the customer’s vehicle is disabled due to any of the following: • Mechanical or electrical breakdown • Dead battery • Flat tire • Lockout • Insufficient supply of fuel, oil, water or other fluids • Entrapment in snow, mud, water or sand within 100 feet of the roadway Towing and Labor service provided by other than one of our authorized service representatives will be reimbursed at reasonable charges, as determined by us. For heavy vehicle types (not available in all states), towing and labor are subject to a deductible and coverage limits as detailed in the policy and declarations page.
Please Select
Please Select
Not Selected
Selected with $250 Deductible
64
Which Fire & Theft with Combined Additional Coverage would you like? * This field is required.The Fire & Theft with Combined Additional Coverage option is a limited form of Comprehensive and only specific perils will be covered. The damage or loss must be caused by fire, lightning or explosion, theft, windstorms or hail, earthquakes, flood or rising waters, vandalism, collision with an animal, or while being transported by a third party.
Please Select
Please Select
Not Selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
65
What is the total value of all permanently attached equipment (including aftermarket parts, mounted equipment, APUs, and modifications)?* This field is required.Permanently- attached equipment means equipment and devices that are permanently installed or attached to your insured vehicle. Permanently- attached equipment also includes: a. accessories designed to work as part of the equipment or devices; b. load securing equipment and devices; and c. custom paint or decals. Examples • Load securing equipment such as tarps, chains and binders • Ladder racking, mounted tool boxes and shelving • Snow treating equipment such as a snow plow, plow harness and salt spreader • Mounted compressor, generator or welding equipment • Vacuuming equipment and accessories • Coupling devices, such as fifth wheel receivers • Electronics (bolted or mounted to the vehicle) • Custom paint, decals or signage
66
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?* This field is required.Permanently- attached equipment means equipment and devices that are permanently installed or attached to the customer’s insured vehicle. Permanently- attached equipment also includes: a. accessories designed to work as part of the equipment or devices; b. load securing equipment and devices; and c. custom paint or decals. Examples • Load securing equipment such as tarps, chains and binders • Ladder racking, mounted tool boxes and shelving • Snow treating equipment such as a snow plow, plow harness and salt spreader • Mounted compressor, generator or welding equipment • Vacuuming equipment and accessories • Coupling devices, such as fifth wheel receivers • Electronics (bolted or mounted to the vehicle) • Custom paint, decals or signage
67
How much did you spend in renting, hiring, or borrowing vehicles last year, including the cost to hire drivers not listed on the policy?Hired Auto provides liability coverage for hired (rented, leased or borrowed) vehicles used for your business.
$5,000 or less
More than $5,000
68
Do you require motor truck cargo coverage?Motor Trucking Cargo coverage pays when the customer is responsible for damage to or loss of the cargo he or she is transporting due to fire, collision or even hitting or running over the cargo being transported.
Yes
No
69
Do you require cargo coverage for mobile/modular homes and buildingsMobile/modular homes and buildings include prefabricated housing units, factory-built homes, mobile homes, tiny homes (less than 500 square feet), modular homes and buildings. Motor homes and travel trailers designed for use on public roads are NOT considered mobile or modular homes.
Yes
No
70
Do you have an interchange agreement requiring trailer interchange coverage?* This field is required.Trailer Interchange covers physical damage to any non-owned trailer while in the customer’s care, custody or control under a lease agreement.
Yes
No
71
Would you like to include General Liability coverage in your quote? * This field is required.General Liability coverage protects your business when you are legally liable for bodily injury/property damage caused by an accident arising out of the your business operations (not directly involving the insured vehicle). Accidents caused by the operation of the insured vehicle are covered under Commercial Auto Liability coverage.
Yes
No
72
How many Non-Owned Trailers do you utilize that will require non-owned physical damage coverage?* This field is required.Non-Owned Trailer Physical Damage provides Collision and Comprehensive coverage for trailers that are not owned you but are used in the course of your business. This coverage is intended for trailers that will be in your possession for less than 30 days at a time. If a trailer is in your possession 30 days or more, the trailer will need to be listed on the policy.
Please Select
Please Select
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20 or more
73
Any other details to assist us make informed decision?
Should be Empty: