Business Insurance Request

1
Image Field
2
Name* This field is required.
First Name
Last Name
3
E-Mail* This field is required.
Email
4
Phone Number
5
Is it okay for TWPIA to text you regarding your quote, policy, billing/payments, service, discounts, promotions, etc?* This field is required.Please note, we do not share or sell SMS opt-in, or phone numbers for the purpose of SMS
YESNO
6
Website
7
Company Name (as registered with the State)* This field is required.
Company Name
8
Business Description* This field is required.
Business Description
9
Business Employee Id Number (EIN)
10
US DOT Number
11
Are you leased to a trucking company?* This field is required.
YESNO
12
Motor Carrier Number
13
Business Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Garaging Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
How long has your business been operating and insured?* This field is required.
New Venture
Less than 1 year
At least 1 year but less than 2
At least 2 years but less than 3
At least 3 years but less than 5
5+ years
16
Vehicles ever operated by driver who are slip seating?* This field is required.
YESNO
17
Do you pull* This field is required.
Doubles
Triples
Both
Neither
18
Do you allow non-employee passengers?* This field is required.
YESNO
19
Services You Offer * This field is required.Select all that apply
Airport
Party Bus
Medical Transport
Charter
Sightseeing
Student Transport
Other
20
Services You Are Interested In ? * This field is required.Select all that apply
General Liability
Commercial Auto
Hired and Non-Owned Auto
Commercial Umbrella Liability
Worker's Compensation
Key-Employee Insurance
Buy-Sell Agreement
Other
21
# of claims within the past 3 years?* This field is required.
optional
22
Range of Operation* This field is required.out of state or remaining in state
Interstate
Intrastate
23
Radius Operation* This field is required.Longest mile radius one way
0-25 miles
26-50 miles
51-100 miles
101-300 miles
500 miles
Unlimited Miles
24
Partner or Drive for any of the following* This field is required.Rideshare/TNC
Uber
Lyft
DoorDash
Medicaid/Medicare Provider
Travel Agency
25
Owner'sInformation
Name
Date of Birth
License #
License State
If applicable, Year CDL Issued
# Moving Violation in last 3 years
# Accidents in the last 3 years
26
Owner's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
27
Does owner drive?Owner
YESNO
28
Driver 1* This field is required.Information
Name
Date of Birth
License #
License State
If applicable, Year CDL Issued
# Moving Violation in last 3 years
# Accidents in the last 3 years
29
Driver 2Information
Name
Date of Birth
License #
License State
If applicable, Year CDL Issued
# Moving Violation in last 3 years
# Accidents in the last 3 years
30
Driver 3Information
Name
Date of Birth
License #
License State
If applicable, Year CDL Issued
# Moving Violation in last 3 years
# Accidents in the last 3 years
31
Any additional drivers?* This field is required.Additional drivers
YESNO
32
Vehicle 1* This field is required.Information
Year
Make
Model
VIN
Vehicle Stated Value
Seating Capacity (Including Drivers)
Vehicle Handicapped Equipped?
33
What type of trailer hitch does vehicle have?* This field is required.
None
5th Wheel
Tow Boom
Ball at Bumper
Ball in Bed
Gooseneck
34
Would you like physical damage coverage?* This field is required.
YESNO
35
Vehicle 2Information
Year
Make
Model
VIN
Vehicle Stated Value
Seating Capacity (Including Drivers)
Vehicle Handicapped Equipped?
36
What type of trailer hitch does vehicle have?
None
5th Wheel
Tow Boom
Ball at Bumper
Ball in Bed
Gooseneck
37
Would you like physical damage coverage?
YESNO
38
Vehicle 3Information
Year
Make
Model
VIN
Vehicle Stated Value
Seating Capacity (Including Drivers)
Vehicle Handicapped Equipped?
39
What type of trailer hitch does vehicle have?
None
5th Wheel
Tow Boom
Ball at Bumper
Ball in Bed
Gooseneck
40
Would you like physical damage coverage?
YESNO
41
Any Additional Vehicles?* This field is required.Additional Vehicles
YESNO
42
Trailer types
43
Trailer 1Information
Year
Make
Model
VIN
Vehicle Stated Value
License Plates Number
44
Would you like physical damage coverage?
YESNO
45
Trailer 2Information
Year
Make
Model
VIN
Vehicle Stated Value
License Plates Number
46
Would you like physical damage coverage?
YESNO
47
Do your vehicles have any of the followings devices?* This field is required.Vehicle Discounts (Select all that apply.)
Telematics
Electronic Logging
On-board Recording
Tracking System Devices
48
Any Additional Vehicles?* This field is required.Additional Vehicles
YESNO
49
Services You Are Interested In ? * This field is required.Select all that apply
General Liability
Commercial Auto
Bobtail Insurance
Hired and Non-Owned Auto
Cargo Liability
Trailer Interchange
Commercial Umbrella Liability
Worker's Compensation
Key-Employee Insurance
Buy-Sell Agreement
Other
50
Combined Single Limits Auto Liability* This field is required.Interstate drivers insurance requirements must meet and be in compliance with FMCSA recommendation. Most federal liability limits are $750,000 or $1,000,000.
$300,000 (Household goods minimum)
$750,000 (General Freight minimum)
$1 ,000,000 (Oil transport minimum)
$1,500,000
$5,000,000 (Hazmat minimum)
51
Vehicle Physical Damage Deductible?* This field is required.If you have enough money in reserve to cover a higher deductible, this can also save another 5-10%.
$1,000
$2,500
$5,000
Higher
52
Cargo CarriedCargo authorized to haul based on SaferWeb www.safer.fmcsa.dot.gov (Select all the apply.)
General Freight
Household Goods
Metal: Sheets, coils, rolls
Motor Vehicles
Drive/Tow Away
Log, Poles, Beams, Lumber
Building Materials
Mobile Homes
Machinery, Large Objects
Fresh Produce
Liquids/Gases
Intermodal Cont.
Oilfield Equipment
Livestock
Grain, Feed, hay
Coal/Coke
Meat
Garbage?Refuse
US Mail
Chemicals
Commodities Dry Bulk
Refrigerated Food
Beverages
Paper Products
Utilities
Agricultural Farm Supplies
Construction
Water Well
53
Motor Cargo Limit
$10k
$25k
$50k
$100k
$200k
54
Do you need a surety bond? * This field is required.VA DMV requires $25k bond or letter of credit on file for 3 years of your operating authority certificate.
YESNO
55
Current Insurance Carrier* This field is required.Unfortunately, for-hire transportation insurance carriers in VA has limited options.
National Indemnity Company (NICO)
Berkshire
Canal
Northland
CHUBB
Lancer
AIC
Progressive
Selective
Erie
Great West
Other
56
How much are you currently paying for insurance?* This field is required.
57
Do you have a copy of your current loss runs (claims history)? If not, please request and email it to us info@twpia.com* This field is required.
New Business
Yes
No
58
How Did You Hear About Us?* This field is required.
Client Referred
Google
Facebook
LinkedIn
YouTube
Event
Radio/Advertisement
Other
59
When is your company looking to make their decision?* This field is required.
Date
Month
Day
Year
Should be Empty: