TRUCKERS QUESTIONNAIRE

Business Information
Business Name:
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website Address
How many years have you been in business?
Are you a subsidiary of another entity, do you have any subsidiaries, or have you operated under a different name?
If yes, prior name:

Historical Operating Information

Radius of Operations (indicate percentage)
Please provide commodity breakdown:
Do you operate as a contract carrier or common carrier?
Any team driving, slip seat driving, or passengers allowed?
Do drivers load and/or unload their units?
Any hazardous material hauled?
Any oversized or overweight loads?
Do you do any hotshot, less than load, express/courier, or last mile operations?
Do you back haul?
If so, provide a copy of the signed contract.
Are you required to provide physical damage on non-owned trailers that are not part of the trailer interchange agreement?
If yes, provide number of non-owned trailers and total value of all trailers
Do you operate as a freight broker or freight fowarder?
Do you arrange loads for others?
Do you operate under a UIIA (Uniform Intermodal Interchange Association) contract?
Do you require filings?
Note: If federal filings are needed, the past 4 quarters of IFTAS are required.
If yes, which filings are required?
Do you engage in operations other than trucking (i.e. warehousing, landfill, towing, etc.)?

Driver Information
Do you use any owner operators (subcontractors)?
If yes - Do they haul exclusively for you?
Do you obtain certificates of insurance?
Provide a copy of the contract for review.
What is the minimum age for drivers?
How many years of experience driving like equipment are required?
What is the maximum number of hours an employee will drive in a 24 hour period?
Are drivers assigned to specific units?
What is annual driver turnover?
How are drivers paid?
Are there formal driver hiring and eligibility guidelines, and MVR standards in place?
If so, please provide a copy of the contract for review.
Do you have a written policy regarding cell phone/mobile device usage?
Are drivers required to wear seatbelts at all times while operating vehicles?
Are MVRs ordered
Do you

Vehicle Information
Are any vehicles garaged in other states?
Are any vehicles or equipment loaned, rented, or leased to others?
Are any vehicles or equipment loaned, rented, or leased from others?
Are any vehicles owned, operated or leased that are not included in the vehicle schedule?
Do you have a formal vehicle inspection and maintenance program in place?
Who is responsible for vehicle maintenance?
Are vehicles equipped with: (Check all that apply)
Number of Vehicle Types Owned
Are any of the following types of trailers used? Check all that apply:
Are double or triple trailers pulled?
Do you haul intermodal containers?
Are loads tarped/covered?

Route Information

What is normal operating radius in miles
What is longest one-way trip in miles
Any routes require overnight stays
Operation territory
Are vehicles governed
Do vehicles/trailers have GPS tracking systems
List states and largest cities entered
How often are drivers home
Are drivers required to have a valid driver's license for at least a minimum number of years
If Yes, please specify Number of years
Are all drivers required to have a CDL for at least 2 years
How many drivers have been driving for you less than 1 year
Do all drivers get road tested
Are daily driving logs kept for each driver
Are DOT files kept on each driver
Describe minimum standards in MVR checking
Pre-employment screening program (PSP) used
Do you verify prior employment
Person responsible for driver supervision
Title/position with firm
List of drivers that includes: the driver's name, DOB, license number, date of hire and years of driving experience. Also include owner operators.
Do you need Comprehensive or Collision coverage to protect this vehicle in an accident or loss?
Is there a permanently attached equipment? in the vehicle?
If yes, what is the value of the permanently attached equipment?

Additional Information
Current Insurance Provider
Preferred Payment Option
Policy Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RMBIA Service Rep Fill out this form?
Have you read the T&C?
Additonal Notes or Comments
Upload Photos, Files, or Documents Here

Cancelof
Please verify that you are human
By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
Should be Empty:

Personal Information