Clone of Insurance Professionals — Intake V1

Primary trucking operation — select one

What is your primary operation?

Briefly describe your operation

Secondary trucking operation (optional)

Where will you operate?

For this quote, how will you operate?

Do you need insurance filings?

Which filings do you need?

Do you need insurance filings?

Filing state

State filing requirement

Choose the requirement listed on your agency’s request. If unsure, choose Not sure.

Insurance filing details (optional)

Tell us the filing type and state, or what you need help confirming.

We’ll help confirm whether filings are needed.

Applicant MC

CPCN

Other authority

Filing details

USDOT status

USDOT number

MC status

Your MC Number

Leave blank if not assigned.

CPCN number

Other authority type

Other authority number

Owner/principal full name

Estimated annual fleet miles

Registration document status

IFTA document status

Loss runs document status

Prior policy document status

Other document status

Producer / prepared by

Coverage Types

Carrier’s USDOT Number

Does your business operate as a freight broker or freight forwarder?

Auto Liability: which types would you like quoted?

Broker / forwarder auto liability

Which coverages would you like quoted?

Auto Liability limit

Auto Liability deductible

General Liability aggregate limit

General Liability deductible

Primary Auto Liability requested limit

Primary Auto Liability requested limit amount ($)

Non-Trucking Liability requested limit

Non-Trucking Liability requested limit amount ($)

Unladen Liability requested limit

Unladen Liability requested limit amount ($)

Contingent Auto Liability requested limit

Contingent Auto Liability requested limit amount ($)

Broker / forwarder cargo requests

Motor Truck Cargo requested limit

Motor Truck Cargo requested limit amount ($)

Motor Truck Cargo requested deductible

Motor Truck Cargo requested deductible amount ($)

Contingent Cargo requested limit

Contingent Cargo requested limit amount ($)

Contingent Cargo requested deductible

Contingent Cargo requested deductible amount ($)

Freight Forwarder Cargo Liability requested limit

Freight Forwarder Cargo Liability requested limit amount ($)

Freight Forwarder Cargo Liability requested deductible

Freight Forwarder Cargo Liability requested deductible amount ($)

Physical Damage: what would you like quoted?

Trailer Interchange requested limit

Trailer Interchange requested limit amount ($)

Trailer Interchange requested deductible

Trailer Interchange requested deductible amount ($)

Is there a written trailer interchange agreement?

Trailer Interchange review

We’ll help confirm your interchange agreement and the coverage you need. This request needs review.

Non-Owned Trailer Physical Damage requested limit

Non-Owned Trailer Physical Damage requested limit amount ($)

Non-Owned Trailer Physical Damage requested deductible

Non-Owned Trailer Physical Damage requested deductible amount ($)

On-Hook requested limit

On-Hook requested limit amount ($)

On-Hook requested deductible

On-Hook requested deductible amount ($)

Garagekeepers requested limit

Garagekeepers requested limit amount ($)

Garagekeepers requested deductible

Garagekeepers requested deductible amount ($)

General Liability requested per-occurrence limit

General Liability requested per-occurrence limit amount ($)

General Liability requested aggregate limit

General Liability requested aggregate limit amount ($)

Number of employees

Employers’ Liability Limits

Each accident / Disease policy limit / Disease each employee

Estimated annual payroll

Estimated annual payroll amount ($)

Would you also like a quote for your BMC-84 surety bond?

Which bond would you like quoted?

Bond jurisdiction

Agency or bond requirement

Name the agency and bond type, or briefly describe the request. You can attach the request under Upload Documents.

BMC-84 Freight Broker / Forwarder Bond
Bond amount: $75,000. Premium quoted separately.

Auto Liability Limit

Maximum Cargo Value

Total Estimated Equipment Value ($)

Combined value of the trucks and trailers you want insured for physical damage.

When would you like coverage to start?

Date

Coverage start date

Truck count status

How many trucks do you expect to insure?

Trailer count status

How many trailers do you expect to insure?

Driver count status

How many drivers do you expect to insure?

What can we help you with?

Year Business Started (legacy)

Operating radius

Primary states of operation

Commodity hauled

Carrier’s Legal Name

Does the leasing carrier provide primary auto liability?

Currently insured?

Current carrier

Policy expiration date

Date

Approximate annual premium

Reason for shopping

Is there an expected lapse?

How would you like to provide equipment details?

Equipment 1

Equipment rows to open

Equipment 1 — Unit Number

Equipment 1 Year

Equipment 6 — Unit Number

Equipment 1 Make

Equipment 1 Model

Equipment 1 VIN

Equipment 1 Type

Equipment 1 Ownership

Equipment 1 — Estimated current value ($)

Comprehensive Deductible

Comprehensive Deductible amount ($)

Collision Deductible

Collision Deductible amount ($)

Equipment 2 — Unit Number

Equipment 2 Year

Equipment 2 Make

Equipment 2 Model

Equipment 2 VIN

Equipment 2 Type

Equipment 2 — Estimated current value ($)

Equipment 2 Ownership

Equipment 3 — Unit Number

Equipment 3 Year

Equipment 3 Make

Equipment 3 Model

Equipment 3 VIN

Equipment 3 Type

Equipment 3 — Estimated current value ($)

Equipment 3 Ownership

Equipment 4 — Unit Number

Equipment 4 Year

Equipment 4 Make

Equipment 4 Model

Equipment 4 VIN

Equipment 4 Type

Equipment 4 — Estimated current value ($)

Equipment 4 Ownership

Equipment 5 — Unit Number

Equipment 5 Year

Equipment 5 Make

Equipment 5 Model

Equipment 5 VIN

Equipment 5 Type

Equipment 5 — Estimated current value ($)

Equipment 5 Ownership

How would you like to provide trailer details?

Equipment 6 Year

Equipment 6 Make

Equipment 6 Model

Equipment 6 VIN

Equipment 6 Type

Equipment 6 Ownership

Equipment 6 — Estimated current value ($)

Equipment 7 — Unit Number

Equipment 7 Year

Equipment 7 Make

Equipment 7 Model

Equipment 7 VIN

Equipment 7 Type

Equipment 7 Ownership

Equipment 7 — Estimated current value ($)

Equipment 8 — Unit Number

Equipment 8 Year

Equipment 8 Make

Equipment 8 Model

Equipment 8 VIN

Equipment 8 Type

Equipment 8 Ownership

Equipment 8 — Estimated current value ($)

Equipment 9 — Unit Number

Equipment 9 Year

Equipment 9 Make

Equipment 9 Model

Equipment 9 VIN

Equipment 9 Type

Equipment 9 Ownership

Equipment 9 — Estimated current value ($)

Equipment 10 — Unit Number

Equipment 10 Year

Equipment 10 Make

Equipment 10 Model

Equipment 10 VIN

Equipment 10 Type

Equipment 10 Ownership

Equipment 10 — Estimated current value ($)

Driver documents: Upload CDLs and driver schedules in the consolidated document section at the end. Leave Date Hired blank if unknown; choose Not applicable—owner when appropriate. Driver 1 is included in your stated driver total.

How would you like to provide driver details?

Driver 1

Drivers to enter now

Driver Name

First NameLast Name

Date of Birth

Date

License State

License Class

License Number

Driver 1 — Driving experience (years)

Driver 1 — Date Hired (optional)

Date

Driver 1 — Date Hired status

Driver 2 Name

First NameLast Name

Driver 2 Date of Birth

Date

Driver 2 License State

Driver 2 CDL Class

Driver 2 License Number

Driver 2 — Driving experience (years)

Driver 2 — Date Hired (optional)

Date

Driver 2 — Date Hired status

Driver 3 Name

First NameLast Name

Driver 3 Date of Birth

Date

Driver 3 License State

Driver 3 CDL Class

Driver 3 License Number

Driver 3 — Driving experience (years)

Driver 3 — Date Hired (optional)

Date

Driver 3 — Date Hired status

Driver 4 Name

First NameLast Name

Driver 4 Date of Birth

Date

Driver 4 License State

Driver 4 CDL Class

Driver 4 License Number

Driver 4 — Driving experience (years)

Driver 4 — Date Hired (optional)

Date

Driver 4 — Date Hired status

Are the vehicles kept at your business address?

Garaging address

Street Address

CityCountryStateZIP Code

Driver 5 Name

First NameLast Name

Driver 5 Date of Birth

Date

Driver 5 License State

Driver 5 CDL Class

Driver 5 License Number

Driver 5 — Driving experience (years)

Driver 5 — Date Hired (optional)

Date

Driver 5 — Date Hired status

Let's Get Started

Your Business

Your Business

Business & Mailing Address

Your Contact

Your trucking operation & coverage

Current insurance

Trucks, Trailers & Drivers

Drivers

Finish & Send

Business details

A few final questions