0%
completed
0
/
fields populated.
Please submit your completed form.
Truckers Quote Intake
Prompts for collecting information for Truckers insurance
Applicant Name
*
Applicant Phone Number
*
Who referred you to our Agency?
Please Select
Agency Website
Call-In
Existing Customer
Facebook
Google
Instagram
Lead Generator
Referral Partner
Walk-in
The reason we ask is because we run a referral program, where we send a gift card to the individeual/company that referrered you as a thank you!
If referred by person, what is their name / name of their business?
What has you shopping for insurance today?
*
Business Name
*
What type of business do you do?
Please confirm your DOT number
*
What is your Date of Birth?
-
Month
-
Day
Year
Date
Please confirm your garaging address is...
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this the same as your mailing address? If no, what is your mailing address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your radius of operations?
*
Under 300 miles
300 - 500 miles
More than 500 miles
Do you need $1 million in auto liability coverage?
*
Yes
No
Not Sure
Do you want Physical Damage Coverage on your truck (ie. Full Coverage)?
*
Yes
No
If yes to Physical Damage Coverage - What is the Value of the truck?
Do you want Motor Truck Cargo Coverage?
*
Yes
No
Not Sure
If yes to Motor Truck Cargo Coverage, what limits do you need?
What Kind of Vehicles do you have?
*
Tractor (Trailer)
Box Truck
Dump Truck
Pick up Truck
Other
If yes to Tractor, what kind of trailer do you have?
Dry Van
Reefer Trailer (Refrigerated Trailer)
Other
What kind of goods do you haul?
General Freight
Refrigerated Goods
Sand & Gravel
Paper & Plastic Products
Consumer Goods
Other
Do you have the Year, Make, Model of the vehicles? Or the VINs?
*
How many drivers do you have?
*
Names of Drivers and Dates of Birth
Can I have the drivers license information for yourself and the drivers -- the state and numbers
Do you use an electronic logging device?
*
Yes
No
If yes, Awesome we can save you over 20% more! What is the Name of the ELD Vendor?
Motive
Samsara
Geotab
Other
Who are you currently insured with?
*
How much do you currently pay per month?
Do you remember how much you paid for your downpayment?
What is your email address?
*
If we get you a good package, how soon are you looking to switch insurance to us?
Quotes are only valid for 30 days.
If we get you a good package, how soon are you looking to switch your insurance?
-
Month
-
Day
Year
Quotes are only valid for 30 days.
Back
Next
Ending Script / Scheduling Script:
Thank you for providing all this information. I've forwarded it to our Commercial Trucking Team for quotes. An associate will give you a call by the end of the day with an update or any follow up questions.
Submit
Should be Empty: