Commercial Trucking Insurance Quotation Form
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E-Mail
*
Email
Business Owners Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Company Name
*
Company Name
FEIN Number
*
Company Name
Is the Business Mailing Address the Same as the Garaging?
*
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
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
Garaging Address (where will the vehicles be kept?)
*
Street Address
Street Address Line 2
City
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
Type of Commodity Hauled
*
Percentage
*
Type of Commodity Hauled
Percentage
Type of Commodity Hauled
Percentage
Do you ever haul oversize/overweight loads?
*
Yes
No
Do you ever haul hazmat material?
*
Yes
No
What is the maximum distance you travel one way?
*
0-50 miles
100-200 miles
201-499 miles
more than 500 miles
Last 4 Quarters of IFTA's:
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Liability Limit Requested:
*
Please Select
500,000 CSL
750,000 CSL
1,000,000 CSL
Cargo Limit Requested:
*
Please Select
100,000
200,000
300,000
Any other coverages that you would like to include? (Please list)
Upload Loss Runs from the past 3 to 5 years:
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Loss runs, which detail your claims history, can be obtained from your previous agency or insurance carrier. All carriers require these reports in order to provide an accurate quote.
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Please list all Trucks/Trailers
If you have more trucks/trailers than you are able to list on this form please email requests@ipa-insure.com
Year
*
Make
*
Model
*
Vin Number
*
Stated Value
*
Do you have another Truck or Trailer you would like to add?
*
Yes
No
Year
Make
Model
Vin Number
Stated Value
Do you have another Truck or Trailer you would like to add?
Yes
No
Year
Make
Model
Vin Number
Stated Value
Do you have another Truck or Trailer you would like to add?
Yes
No
Year
Make
Model
Vin Number
Stated Value
Do you have another Truck or Trailer you would like to add?
Yes
No
Year
Make
Model
Vin Number
Stated Value
Do you have another Truck or Trailer you would like to add?
Yes
No
Year
Make
Model
Vin Number
Stated Value
Do you have another Truck or Trailer you would like to add?
Yes
No
Year
Make
Model
Vin Number
Stated Value
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Please list all Drivers:
Please list all drivers you would like to have on the quote.
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Years CDL experience
*
Drivers License Number and State
*
Add Another Driver?
*
Yes
No
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Years CDL experience
Drivers License Number and State
Add Another Driver?
Yes
No
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Years CDL experience
Drivers License Number and State
Add Another Driver?
Yes
No
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Years CDL experience
Drivers License Number and State
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Please verify that you are human
*
By clicking "I agree" below: I hereby certify that the information provided in this form is true, accurate, and complete to the best of my knowledge. The information provided in this form is collected for general underwriting and informational purposes only. Coverage selections or requests indicated herein may not be reflected in the quotes you have received. The quotes and policy documents themselves are the sole and controlling source of the coverages, limits, deductibles, endorsements, exclusions, and terms being offered. Applicants are advised to carefully review all quotes and policy documents in their entirety to confirm the exact coverage being proposed prior to binding coverage.
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