Truck Insurance Quote Form

1
Owner's Name?
First Name
Last Name
2
Date of Birth
3
Phone Number
Please enter a valid phone number.
4
Email
example@example.com
5
Preferred Method of Contact
Please Select
Please Select
Phone Call
Email
Text/SMS
6
Your Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / 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
7
Your FEIN
8
Your DOT Number
9
Years of ExperienceAs a business owner
Please Select
Please Select
0
1
2
3
4
5+
10
Is this business a NEW VENTURE?
YESNO
11
Will you be operating under your own DOT number and MC authority?
YESNO
12
Will you lease on to a Motor Carrier?
YESNO
13
Do you have a signed Lease Agreement with the MC Carrier?
YESNO
14
What is the Carrier's MC number?
15
Who is your person of contact at the Carrier?Full Name Phone Number
16
What coverage(s) are you shopping for?Please select all that apply
Primary Liability
Short Term Auto Liability
General Liability
Motor Truck Cargo
Physical Damage
Non-Trucking Liability (NTL)
OCC/ACC
Other
17
Radius of Operation
Please Select
Please Select
1-200 Miles
201-1000 Miles
Over 1000 Miles
18
What commodities do you haul?Please try to be as detailed as possible
19
Are you hauling hazardous materials?
YESNO
20
Does the business require a Hazardous Materials (HAZMAT) placard?
YESNO
21
Are you hauling any of the following: autos, fuel, explosives, or chemicals?
YESNO
22
Do you haul any high-value loads (over $100,000)?
YESNO
23
Do you haul household goods or moving services?
YESNO
24
Do you haul livestock?
YESNO
25
Do you haul sand, gravel, or dirt (dump operations)?
YESNO
26
Do you haul logs or lumber?
YESNO
27
Do you haul intermodal containers?
YESNO
28
Does the business perform repossessions more than 5% of the time?
YESNO
29
Will you act as a freight broker, freight forwarder, or arrange any loads for other companies?
YESNO
30
Has your prior insurance ever been cancelled or non-renewed by any insurer in the past 3 years (for any reasons NOT related to payment of premium)?
YESNO
31
How many liability claims have you had in the past 3 years?
Please Select
Please Select
0
1
2
3
4
5+
32
How long have you had your own continuous commercial auto insurance coverage in the current business name?
Please Select
Please Select
New Venture
1
2
3
4
5+
33
Do you have an up-to-date Loss Run report(s) (last 3 years)?
YESNO
34
Please upload your Loss Run report(s) here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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35
Are vehicles garaged in the same location as the business address? If no, please indicate in next textbox.
YESNO
36
Vehicle(s) Garaging Address
37
Are all trucks titled and registered to the named insured?
YESNO
38
Are all trailers titled and registered to the named insured?
YESNO
39
Do you lease or rent any power units (tractors)?
YESNO
40
Do you lease or rent any trailers?
YESNO
41
Do you use any owner-operators under your authority?
YESNO
42
Will any vehicle(s) be used for personal use?
YESNO
43
Do you have a dash cam installed in the truck(s)?
YESNO
44
Are there any drivers with less than 2 years CDL experience?
YESNO
45
Has any driver had an at-fault accident(s) or violation(s) in the past 3 years?
YESNO
46
Do you expect to add drivers within the next 60 days?
YESNO
47
Do you expect to add (power units) within the next 60 days?
YESNO
48
Do you use any team drivers?
YESNO
49
Do you allow passengers in the truck?
YESNO
50
Have you had any bankruptcies (Chapter 7, 11, or 13) in the past 5 years?
YESNO
51
How would you like to provide Driver License(s) and Unit(s) information?
UPLOAD PHOTOSENTER MANUALLY
52
Driver(s) InformationPlease upload licenses of all drivers
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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53
Vehicle InformationPlease upload photo(s) of all VIN(s) for the vehicles and trailers
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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54
Drivers InformationFull Name: Date of Birth: License Number: License State: License Expiration Date: Years of CDL Experience: Original CDL Issue Date:
Huge
Large
Normal
Small
Ok
Ok
55
Vehicle InformationYear: Make: Model: VIN: Market Value:
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: