Truck Insurance
Requesting Information Questionnaire
For Informational purposes only
Effective Date:
Effective Date:
Effective Date:
SSN:
TAX ID:
Business Details:
Business Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type
Individual
Partnership
Corporation/LLC
Commodities
Phone Number
Format: (000) 000-0000.
E-mail
Radius
0-100 miles
101-300 miles
301-600 miles
Over 600 miles
DOT#
MC#
Loss History/Prior Experience
Rows
Company
Policy Period
Loss Amounts, Desc., Dates (attached separate list if needed)
1
2
3
4
5
Owner/Driver Details:
Rows
Driver Name(s)
DOB
DL#
State of the DL
Experience
Date of Hire
Owner/Driver
1
2
3
4
5
6
7
8
9
10
Vehicles:[Truck/Trailers]
Rows
Year
Make and Model
Vehicle Type
VIN#
Value [If Physical damage]
1
2
3
4
5
6
7
8
9
10
Coverage Details:
Rows
Total Amount Outstanding
Liability Limit
Cargo Limit
Cargo Deductible
Phys. Damage Deductible
UM/UIM Limit
Trailer Interchange
Other Coverage
Refrigeration Breakdown
Yes
No
Cargo % breakdown of commodities
Rows
Commodities
Max Value/Exposure
% of Time Hauled
1
2
3
4
5
6
COMMENTS
Additional Driver/Vehicle Information
The People You Spoke
*
Antonio
Marie
Wendy
Submit
Should be Empty: