Truckers Quote Form

TRUCKING INSURANCE
Owner

First NameMiddle NameLast Name
Phone Number
E-mail
D.O.B.

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
DOT
MC Number
Experience?
Business Operations
Business Type
If Other, please enter below
EIN #
Year Established
Business Operations & Description of Cargo
Please be as specific as possible on the cargo being hauled. If "General Freight" please copy the example & use specifics with %'s.
Radius of Operations
Do you cross state lines?
Do you haul hazardous material
Do you operate on a regular route?
Do you rent/lease your vehicles to others?
ELD? If yes, please list company
Dashcams?
Type of Insurance Requested
Currently Insured?
Which company?
Please submit any and all Declaration pages/Loss Runs/Logs/MVR's to tanner@lighthouseinsures.com
Desired Deductible
Cargo Coverage?
If Yes, please enter amount of coverage below.
Coverage Amount
Do you need a General Liability Policy?
Do you need trailer interchange coverage?
Covers the trailer that is not owned by trucker, but being used under a trailer interchange agreement.
Physical Damage coverage?
Select Comprehensive Deductible
Select Collision Deductible
Do you need workers comp?
Select Desired Limit
Please enter Desired Limit
When would you like this policy to start?

MonthDayYear
Date
Lighthouse Insurance

2915 Bluestem Ln

Murfreesboro, TN 37128

Tanner@lighthouseinsures.com

Cell: 256-863-0617
Office: 629-238-0441
Should be Empty:

Business Operations