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Trucking Quote
Trucking Quote
mike hart
2024-05-09T22:50:58+00:00
"
*
" indicates required fields
1
Basic Info
2
Contact(s)
3
Trucks & Trailers
4
Drivers
5
Commodities
6
Additional Insureds
7
Wrapping Up
Basic Information
Is your business currently insured?
Yes
No
Insurance Carrier Name
*
How many years of insurance under the same business name?
*
Current policy expiration date
*
Month
Day
Year
Why are you looking to replace your current policy?
Is this a New Venture or was there a Lapse in Coverage?
*
i.e. General Liability, Business Owners Policy, etc.
New Venture
Lapse in Coverage
Does the business have other types of insurance?
*
i.e. General Liability, Business Owners Policy, etc.
Yes
No
Desired Coverages
*
(Select all that apply)
Auto Liability
Physical Damage
Cargo
General Liability
Bobtail
Non-Trucking Liability
Umbrella / Excess
Commercial Property
Occupational Accident
Workers Comp
Hired/Non-Owned Auto
What Effective Date do you want the policy to be?
*
MM slash DD slash YYYY
Do you have a DOT#?
*
Yes
No
Pending
DOT#
*
Do you have an MC#?
*
Yes
No
Pending
MC#
*
Do you have a Tax ID Number?
*
Yes
No
Pending
EIN / TNN
*
How is the business structured?
*
Sole-Proprietor
Partnership
LLC
Corporation
Other
What is the Name of the Business?
*
Has the business either Currently or Previously operated under a DBA?
No
Yes
DBA
*
Website
Business Mailing Address
*
Street Address
Address Line 2
City
Zip Code
State Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
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
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Business Garaging Address
Same as Mailing Address
Business Mailing Address
*
Street Address
Address Line 2
City
Zip Code
State Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
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
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Are all vehicles garaged at the same location?
*
Yes
No
Year Business Established
*
Primary Contact
Name
*
First
Last
Date of Birth
*
Month
Day
Year
Phone
*
Mobile Phone
Can we text you?
*
Yes
No
Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel.
Privacy Policy
Email
*
Designated Financial Responsibility for Company?
*
Yes
No
What is your Role?
*
Owner / Operator
Management
Other
Owner / Operator
- Both a Manager and included on the policy as a Driver.
Manager
- Strictly a manager, is NOT a Driver on the policy.
Other
- Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.
Owner's Address
Drivers License Numbe
*
Drivers License State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
CDL Year Originally Issued?
*
How many years of Management Experience?
How many years of Trucking Experience?
*
Is there a Secondary business contact?
*
No
Yes
Secondary Contact
Secondary Contact: Name
*
First
Last
Secondary Contact: Date of Birth
*
Month
Day
Year
Secondary Contact: Phone
*
Secondary Contact: Email
*
Secondary Contact: What is your Role?
*
Owner / Operator
Management
Financial Responsibility
Other
Owner / Operator
- Both a Manager and included on the policy as a Driver.
Manager
- Strictly a manager, is NOT a Driver on the policy.
Other
- Anyone besides the Owner / Management that has been authorized to contact us on their behalf, particularly to make modifications to their Policy / Coverages.
Truck(s) Information
Trucks List
VIN
Year
Make
Model
Actions
Edit
Delete
There are no
Truck.
Add Truck
Maximum number of truck reached.
Do you have any trailers you want to insure?
Yes
No
Trailer(s) Information
VIN
Year
Make
Model
Actions
Edit
Delete
There are no
Truck.
Add Truck
Maximum number of truck reached.
Driver(s)
Do you have additional drivers?
Yes
Drivers List
Driver Name
Date of Birth
Drivers License #
Drivers License State
Actions
Edit
Delete
There are no
Driver.
Add Driver
Maximum number of driver reached.
Commodities
What type(s) of commodities do you haul? The grand total of all commodities should equal 100%.
Commodity 1
Commodity Type
Aircraft / Auto / Boats
Building Supplies
Chemicals
Construction Materials
Consumer Goods
Farming / Agriculture / Livestock
Food & Beverage
Machinery & Equipment
Metals / Minerals / Coal
Miscellaneous
Paper / Plastic / Glass
Commodity
Commodity 1 Percent
*
Add Another Commodity
Add Another Commodity
Commodity 2
Commodity Type
Aircraft / Auto / Boats
Building Supplies
Chemicals
Construction Materials
Consumer Goods
Farming / Agriculture / Livestock
Food & Beverage
Machinery & Equipment
Metals / Minerals / Coal
Miscellaneous
Paper / Plastic / Glass
Commodity
Total Commodity Percent
This should equal 100%
Other commodities not listed above
If you haul other commodities not listed above, please enter them here.
Other commodities not listed above
If you haul other commodities not listed above, please enter them here.
Additional Insured(s)
Does anyone need to be listed as Additional Insured
Yes
No
Additional Insured(s) Information
Additional Insured Files
If your AIs have documents or requirements you may upload those here.
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 2 MB, Max. files: 10.
Name of the owner of this business
*
Address of business owner
*
Would you like a quote from a specific agent?
Would you like a quote from a specific agent?
Angelyn Hart
How were you referred to us?
Additional Comments
Attach File(s)
Drop files here or
Select files
Accepted file types: pdf, png, jpg, Max. file size: 1 GB.
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