Trucker Insurance

Trucks and Drivers

This information is vital, and required, for me to get your insurance quote. Please fill it out completely and accurately. If you have all your truck and driver information as a spreadsheet, or document, you can upload it instead.
Trucks and Trailers
Drivers
Business Owner also a driver?

YesNo
Owner Name
Owner Date of Brith

MonthDayYear
Owner Driver License #
Sometimes needed to verify that owner cannot be driver (ie. no Class A license)
Upload (optional): If you have a spreadsheet, document, prior insurance declaration page, etc. with all this information, you can upload it instead.

Cancelof

Previous and Current Insurance Providers and Loss History
Do you have active insurance now?

YesNo
Are you getting non-renewed, or just exploring options?

Non-renewedExploring options
Please send, or upload your non-renewal letter at the end of this form.
What's the yearly premium you're trying to beat?
Has your insurance ever been cancelled or been lapsed?

YesNo
Why was it cancelled or lapsed?
Prior and Current Insurance Providers and Claims (most insurance providers require 3 years of history)
Describe any Accident or Claims in the last 3 years
Are any still ongoing, pending legal resolution, have police report showing no-fault, etc?

Contact Information
Phone Number*
Email*
Effective Date

MonthDayYear
What day do you need the insurance to take effect? If you are renewing, this would be the same day your current policy expires. If you need it ASAP, put today.
Upload relevant information. For example: IFTA reports (last 4 complete quarters), Loss Runs (last 3 years), cancellation or non-renewal letter, Trailer Interchange or UIIA agreement, current insurance policy, vehicle registration card, previous CDL, etc.

Loss Run and IFTA are almost always a requirement if they are applicable. If you don't have those yet, that's okay, but please be prepared to gather them soon.
Cancelof
Do you have any other information, questions, or comments to share?
Please verify that you are human*
Should be Empty:

Company Information continued