Quote



How did you hear about us?:
Business Owner:
   First Name:
 
   Last Name:
Date of Birth:
Business Name:
Type of Business:
Address:
Garage City:
County:
State:
Zip:
Is the mailing and garaging address the same?
If not enter Garaging address here:
Home/Office Number:
- -
Cell Phone Number:
- -
Fax Number:
- -
Email Address:
Confirm Email Address:
Federal Employer Identification
or Social Security number:
Number of years in business?:
MC Number:
DOT Number:
What states or areas do you
typically travel to?
Commodities hauled:
1
%
 
2
%
 
3
%
 
4
%
 
 
 
Equals 100%
 
Tractors, Trailers, & Straight Trucks
1
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
2
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
3
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
4
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
5
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
6
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
7
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
8
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
9
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
10
Truck/Trailer Type
Year
Make
Model
Radius of Operation
VIN #:
GVW
Stated Value: $
Deductible
If you have more than 10 units, please note this information at the end of the quote form in the
"Other important information section"
  Operations Beyond 300 mile radius – Identify Metropolitan Areas traveled Through or Into:
   Atlanta    Cleveland    Jacksonville    Milwaukee    Orlando    Salt Lake City
   Balt-Washington    Dallas/Ft. Worth    Kansas City    Mpls./St. Paul    Philadelphia    San Diego
   Boston    Denver    Little Rock    Nashville    Phoenix    San Francisco
   Buffalo    Detroit    Los Angeles    New Orleans    Pittsburgh    Seattle
   Charlotte    Hartford    Louisville    New York City    Portland    Tampa
   Chicago    Houston    Memphis    Oklahoma City    Richmond    Tulsa
   Cincinnati    Indianapolis    Miami    Omaha    St. Louis    
Drivers
1
Driver: First Name
Last Name
Date of Birth
License Number
Licensed State
Years of CDL
Experience
# of Violations
# of Accidents
Date Hired
2
Driver: First Name
Last Name
Date of Birth
License Number
Licensed State
Years of CDL
Experience
# of Violations
# of Accidents
Date Hired
3
Driver: First Name
Last Name
Date of Birth
License Number
Licensed State
Years of CDL
Experience
# of Violations
# of Accidents
Date Hired
4
Driver: First Name
Last Name
Date of Birth
License Number
Licensed State
Years of CDL
Experience
# of Violations
# of Accidents
Date Hired
5
Driver: First Name
Last Name
Date of Birth
License Number
Licensed State
Years of CDL
Experience
# of Violations
# of Accidents
Date Hired
Please explain any moving violations (date and type) and give dates of any accidents in the box below:
Primary Liability Insurance:
Primary Liability Insurance Limit:
Cargo Insurance Needed?
Insurance Limits:
Cargo Deductible:
Refrigeration breakdown coverage:
Do you need to insure someone
else’s trailer?
If so, how much value do you need on Trailer Interchange:
Total Revenue for the past year:
Total Mileage for the past year:
Do you want general liability
insurance?
If yes:Total payroll amount:
Total driver payroll amount:
Name of current insurance
company:
Policy Number:
Policy Begin Date:
Insurance Company Name
2nd Year Back:
Insurance Company Policy Number
2nd Year Back:
Insurance Company Name
3rd Year Back:
Insurance Company Policy Number
3rd Year Back:
How many losses have you had in
the last three years?:
Please choose a signature style that
will provide us permission to request
your loss runs from previous carriers:
Full name
Full name
Full name
Full name
Full name
If you have scanned loss runs click here:
Or Fax to 888-812-2572
If you have scanned IFTA's click here:
Or Fax to 888-812-2572
Why are you shopping for new
coverage?:
Other information you feel may
assist us in providing you a quote:
Verification:
1 + 14=