Truck Insurance Quick Quote Application
Arceri & Associates, Inc.
What is your effective date of coverage?
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
Company Name
*
Phone #
*
504-555-9988
E-mail
*
example@example.com
DOT #
MC #
ELD NAME
EIN # or SS #
Physical Address
City
State
Zip Code
Is the mailing address the same as the physical address?
Yes
No
Mailing Address
City
State
Zip Code
Yrs. Trucking Experience
*
Yrs. in Business
Yrs. CDL "A" License
New Venture (Under 2 yrs)
YES
NO
New Venture Questions
If you are a new venture, answering these questions is required.
Are you applying for DOT Authority?
YES
NO
Do you expect to increase the number of power units within one year?
YES
NO
If yes, how many units will you be adding?
Will you allow trip leasing?
YES
NO
Will you be using team drivers?
YES
NO
Does anyone ride with you?
YES
NO
What is your driver hiring process?
What is your Vehicle Maintenance Program?
Scheduled Vehicles (Trucks/Tractors)
Upload a copy of your Vehicle(s) Registration Here or Complete the Vehicle Info Below.
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Truck Vehicle #1
ADD - 2ND TRUCK / TRACTOR / POWER UNIT
Truck Vehicle #2
ADD - 3RD TRUCK / TRACTOR / POWER UNIT
Truck Vehicle #3
ADD - 4TH TRUCK / TRACTOR / POWER UNIT
Truck Vehicle #4
ADD - 5TH TRUCK / TRACTOR / POWER UNIT
Truck Vehicle #5
Scheduled Vehicles (Trailers)
Upload a copy of your Trailer(s) Registration Here or Complete the Vehicle Info Below.
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Trailer #1
ADD - 2ND TRAILER
Trailer #2
ADD - 3RD TRAILER
Trailer #3
ADD - 4TH TRAILER
Trailer #4
ADD - 5TH TRAILER
Trailer #5
Scheduled Drivers
Upload Copies of the Driver's License for EACH Scheduled Driver or Complete the Info Below.
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Driver 1 Name
Driver 1 Date of Birth
Driver 1 Drivers License #
Driver 1 State of License
Driver 1 Years of CDL "A" Exp
Driver 1 Year Hired
ADD 2ND DRIVER
Driver 2 Name
Driver 2 Date of Birth
Driver 2 Drivers License #
Driver 2 State of License
Driver 2 Years of CDL "A" Exp
Driver 2 Year Hired
ADD 3RD DRIVER
Driver 3 Name
Driver 3 Date of Birth
Driver 3 Drivers License #
Driver 3 State of License
Driver 3 Years of CDL "A" Exp
Driver 3 Year Hired
ADD 4TH DRIVER
Driver 4 Name
Driver 4 Date of Birth
Driver 4 Drivers License #
Driver 4 State of License
Driver 4 Years of CDL "A" Exp
Driver 4 Year Hired
ADD 5TH DRIVER
Driver 5 Name
Driver 5 Date of Birth
Driver 5 Drivers License #
Driver 5 State of License
Driver 5 Years of CDL "A" Exp
Driver 5 Year Hired
If you have more than 5 Drivers Upload a Complete Scheduled List Here. You can also upload FRONT & BACK copies of Driver's Licenses Here.
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Coverage, Limits
Upload a copy of your Declaration Pages Showing All Coverages or Select the Limits Below
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Select Auto Liability Limit
$1 Million
$750,000
$500,000
$300,000
Other
Select - Auto Liability Deductible (Discounts Available)
None
$500
$1,000
$2,500
$5,000
Other
Do you need H/NO?
YES
NO
SELECT IF NEEDED
Hired Auto
Non-Owned Auto
UIIA
REQUIRED BY CONTRACT?
Do you need a AI / WOS?
Additional Insured
WOS Required
NAME / ADDRESS OF COMPANY REQUIRING AI OR WOS
Do you want Comprehensive & Collision (Full Coverage) Physical Damage on your Vehicles?
Yes
No
Comp / Collision Deductible
$1,000
$2,500
$5,000
Other
Do you want Auto Medical Payments?
Yes
No
Medical Payments Limit
$1,000
$2,500
$5,000
Other
Do you want Uninsured Motorists?
Yes
No
UM Bodily Injury
$30,000
$100,000
Other
UM Property Damage
Accept
Reject
Do you want Cargo Insurance?
Yes
No
Cargo Limit
$250,000
$100,000
Other
Cargo Deductible
$1,000
$2,500
Other
Reefer Breakdown
Yes
No
Do you want Trailer Interchange?
Yes
No
Trailer Interchange
$25,000
$40,000
$50,000
Other
Do you want General Liability Coverage?
Yes
No
Gen. Liability Limit
$1 Million
$750,000
$500,000
$300,000
Other
Towing & Motor Club
Yes
No
Do you want a quote on Workers Comp?
Yes
No
Do you want a for Occupational Accident?
Yes
No
Radius, Mileage, Cities, Commodities
What is your AVERAGE Radius of Operation?
0 - 100 Miles
100 - 300 Miles
300 - 500 Miles
500+ Miles
Other
What are your Estimated Annual Miles Driven?
List SEVERAL CITIES where you may travel.
COMMODITIES HAULED (Select all that apply)
What is the AVERAGE ($)VALUE of Commodity Hauled?
What is the MAXIMUM ($)VALUE of Commodity Hauled?
General Questions
Select "Yes" or "No" for the following questions. Explain if required.
1. Have you ever operated a trucking business under a different Authority or Name?
YES
NO
2. Do you operate as a Freight Forwarder, Freight Broker or arrange loads for others under the same MC/DOT Numbers as the trucking authority?
YES
NO
3. Do you own or use any equipment not scheduled on this application?
YES
NO
4. Are loaded trailers ever left overnight, unattended or detached from power units?
YES
NO
5. Have you ever filed for bankruptcy?
YES
NO
6. Do you ever haul oversized/overweight loads?
YES
NO
7. Do you ever loan, lease or rent equipment to others?
YES
NO
Explain any YES answers above.
Insurance Information
(Please be specific)
Who is your current Insurance Company?
What is your current Policy #?
What is your Current Annual Premium ?
For all your coverage
What is a Target Premium ($) ?
What would you like to pay?
Has your insurance ever cancelled or non-renewed?
Yes
No
If Cancelled or Non-Renewed, Why?
Failure to Provide Documentation
Incurred Losses
Material Change in Risk
Non-Payment of Premium
Other
Have you had any losses or claims in the last 5 years?
YES
NO
Upload a copy of "LOSS RUNS" Here. (Current and any previous Insurance - Even if the policies were cancelled or short term coverage)
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Upload IFTA's Reports Here
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Discounts
Some carriers offer discounts for the following?
Are you open to using driver usage-based TELEMATICS DEVICES to record miles driven, geo-location, driving behavior, etc in order to lower your premium? (not mandatory)
Yes
No
Are you open to using driver (Dual Facing) IN CAB CAMERAS in order to lower your premium? (not mandatory)
Yes
No
Are you open to using (SIR's) Self-Insured Retentions or Deductibles on AUTO LIABILITY in order to lower your premium? (not mandatory)
Yes
No
How did you hear about us?
Please Select
Chris Arceri
Joel Overton
Ruth
Postcard
Phone Call
Referred by friend/client
Google Search
Text Message
Email
CTQ
ADD NOTES OR COMMENTS HERE.
Signature of Insured
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