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?

None0-1 year1-2 years2-3 years3+ years
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?

YesNo
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

Type of Insurance Requested