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To obtain a quote, please fill out the form below. We will contact you at the telephone number provided within 48 hours. Your information is confidential and will be used only for insurance purposes. All fields do not need to be filled out for submission.
Date of Quotation:
How did you hear about us?:
Select one
flyer
referral
website
other
Effective Date:
Name:
DBA:
Address:
City/State/Zip:
Telephone:
Pager:
Fax:
Mobile:
E-Mail:
California PUC #:
ICC #:
Tax ID #:
Type of Ownership
Individual
Partner
Corp
Authority
Contract Carrier
Common Carrier
DOT Safety Rating:
Select one
Satisfactory
Unsatisfactory
Unknown
Garage Address:
City/State/Zip:
Years in Business:
Years Experience:
Commodity Hauled (Percentage):
Routes of Travel (Major Cities and Percentage):
Gross Receipts:
Current Est.
Year 1
Year 2
Year 3
Subhaul Exposure:
Yes
No
If yes, cost of hire
Coverages:
LIA:
GL:
Phys., Dam., Ded.:
CARGO $:
DED $:
Reefer B/D:
Yes
No
Average Cargo Limit:
Type of Reefer Unit:
When Serviced:
Vehicle Maintenance Program:
Previous Carriers and Experience:
YEAR
COMPANY
POLICY #
#OF CLAIMS (TYPE)
New Venture - Must be completed if three years prior carrier information is not supplied.
YEAR
EMPLOYER
ADDRESS
LOSS INFORMATION
Show % of Trips:
0 to 75 miles:
76 to 150 miles:
151 to 300 miles:
301 to 500 miles:
For trips over 500 miles, select the states you travel in and indicate the percentage of trips into each zone
Zone 01:
CT
DE
ME
MD
MA
NH
NJ
NY
RI
VT
Zone 02:
AL
CA
FL
GA
IL
IN
MI
NC
OH
PA
SC
VA
WV
Zone 03:
AZ
AR
KY
LA
MN
MS
MO
OK
OR
TN
TX
WA
WI
Zone 04:
CO
ID
IA
KS
MT
NE
NV
NM
ND
SD
UT
WY
Schedule of Equipment:
YEAR
MAKE
BODY TYPE
SERIAL #
ANN. MILES
RADIUS
VALUE
Drivers:
Name
DOB
COMM. DRIVING EXP.
yrs.
License #
SSN #
RECORD - Tickets
Accidents
Date of Hire
Name
DOB
COMM. DRIVING EXP.
yrs.
License #
SSN #
RECORD - Tickets
Accidents
Date of Hire
Name
DOB
COMM. DRIVING EXP.
yrs.
License #
SSN #
RECORD - Tickets
Accidents
Date of Hire
Name
DOB
COMM. DRIVING EXP.
yrs.
License #
SSN #
RECORD - Tickets
Accidents
Date of Hire
Comments/Loss Explanations:
Please enter the text in the image shown for verification:
