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Quick-Quote.me Commercial Auto / Truck / Fleet Insurance With Several Leading Insurers

To Get A Quick-Quote Complete The Below Underwriting & Rating Information Form

 

 

                           

                         We Welcome Truckers (including owner-operators) / Retail Delivery Fleets / Truck Dealers   

 

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Commercial Auto/Truck/Fleet Insurance Quote Request

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

General Information:

* Business Name   

Type of Business :

*Contract - Full Name:

Describe Operations :

  * Title / Position:   Business Model:  
  *Employers Federal Tax Id # (FEIN) 

 Select Type Coverage Below That You Would Like Us To Quote:

*Contact Phone:

 Cell # 

          Workers Comp:

General Liability:

   *Fax:

  Commercial Property:      Commercial Auto:       Business Equipment & Contents

Web Site Address:

 

Umbrella Liability:Professional Liability : Cargo/Freight

Other - Please specify or describe:

*Email:

          

*Send Quick Quote By : Email Fax Both

Current Insurance Carriers Name :  

Expiration Date: 

 *Business Address:          

 Address:  

City:

 State: Zip :

County:

Mailing Address:          Same as Mailing Address
 Address:
 

City :

State:    Zip: 

County : 

 

General Information:

 

Years in Business: Number of Employees:

                    # Full Time:  # Part Time:

Approx. Annual Payroll $:

 Approx Annual Gross Receipts $:

Commercial Truckers Only                                                                                    Select Farthest Zone From Your Location - City 1st or Region 2nd

 

 
Locations: Check Here If You Have More Than 4 Locations ( We will be contacting you by telephone or email to get additional location information )
Location # Street City State Zip Code County Number Of Employees
 

Commercial Driver Information:

Please list all employees who are licensed commercial drivers; even if you do not wish to cover them for use of your vehicles..

         History :  Any reportable Accidents/Major Violations/Comp Claims within the past 5 years or minor violations within past 3 years?Need help with these questions call 1-800-361-8734 !

Driver 1

Full Name


 

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 2

Full Name

 

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 3

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 4

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 5

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 6

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 7

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 8

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 9

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Driver 10

Full Name

Driver's License #

State

DOB

 

At Fault Accidents/Major Violations 

Not At Fault Accidents                   

Minor Moving Violations/Tickets     

Does Your Business Employ More Than 10 Drivers - Yes  No   

 

Commercial Vehicle Information:

Vehicle Number

Year

Make / Type

Model /  Date Purchased / Cost

Vehicle ID Number This Is A 17 Digit Number (Numeric & Alpha) - Need help with this locating your Vehicle Identifcation Number (VIN) call 1-800-361-8734 !

( This  is a 17 Digit Number)

Driver#

Weight / Usage / Miles / Trailer Hitch

Vehicle 1

Model    Date Purchased  

Cost New $ Current    $

 

 

Vehicle 2

  

 

Model    Date Purchased    

Cost New $ Current    $

 

Vehicle 3

Model    Date Purchased    

Cost New $ Current    $

 

Vehicle 4

Model    Date Purchased   

Cost New $ Current    $

 

Vehicle 5

 

 

 

 

Model    Date Purchased   

Cost New $ Current    $

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle 6

 

 

Model    Date Purchased   

Cost New $ Current    $

Vehicle 7

  

Model    Date Purchased   

Cost New $ Current    $

 

Vehicle 8

Model    Date Purchased  

Cost New $ Current    $

 

Vehicle 9

      

Model    Date Purchased   

Cost New $ Current    $

 

Vehicle 10

 

 

 

 

 Model    Date Purchased    

Cost New $ Current    $

 

 

 

 

 

 

 

 

 

 

Does Your Business Operate More Than 10 Vehicles?  No Yes   

 If "Yes"  please indicate total number of vehicles and we will email you a supplemental vehicle schedule )

Coverage Limits:

 Vehicle  Number

BI/PDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

 UMBI/PDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

  PIP/MEDNeed help with selectiing or understanding what this coverage provides call 1-800-361-8734 !

COMP Ded

COLL Ded

Towing

                  Rental Car

Vehicle 1

Vehicle 2

 same as vehicle 1

same as vehicle 1 same as vehicle 1

Vehicle 3

 same as vehicle 1

same as vehicle 1 same as vehicle 1

Vehicle 4

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 5

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 6

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 7

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 8

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 9

same as vehicle 1 same as vehicle 1 same as vehicle 1

Vehicle 10

same as vehicle 1 same as vehicle 1 same as vehicle 1

 
 Commercial Vehicle Claim/Loss History Information:
  Loss History Information:

Our Insurance Company Underwriters May Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

 

 *Has your business had any losses or filed a commercial auto claim in the last five years? YesNo

 

If "Yes" Please Briefly Provide Details ( amount paid / carrier / policy # /  date of injury / nature of accident / injury sustained) or

Send Us Your Prior Insurers Valued Loss Runs For The Past 5 Years to:  edhemphill@hemphillinsuranceagency.com or fax (936) 448-1013.

 

  General Underwriting Information: Need help with these questions call 1-800-361-8734 ! Please review each check box below to assure that each question is correctly answered; then change the checked box to the most appropriately response that applies to your request for a rate quote. Incorrect information may void the quick quote rate you receive.

 1. Is coverage requested for all of business' commercially owned and operated vehicles? YesNo

 2. Are any state or federal flings required ?YesNo

 3. Are there any Additional Insured's that need to listed on you policy as a named insured for coverage ?YesNo  

 4. Does your business need to provide any other entity or person with a Waiver of Subrogation to restrict your firm or insurance carriers right of subrogating

against them in the event of another parties negligence ?YesNo  

 5. Does your business own/lease/rent any trailers ?YesNo

 6. Are any of your firm's business vehicles used by family members who are not actively employed in your business ?YesNo

 7. Are any of your business vehicles used to transport people or property for hire?YesNo

 8. Is the primary purpose of any vehicle listed above to transport person; other than your employees ?YesNo

 9. Does you business require or allow any employees to use their personally owned/  leased /or hired vehicles for business purposes? YesNo   

   If " Yes " we recommend adding a hired/non-owned endorsement to your commercial auto liability coverage.

10. Is your firm a subsidiary of another entity? YesNo

11.  Is a formal written safety program in operation? YesNo

12.  Does your firms have any subsidiaries ? YesNo

13.  Any exposure to flammables, explosives , chemicals, or other hazardous materials ? YesNo

14. Any catastrophe exposures ? Yes No

15. Are you currently insured for other types of coverage with any of the insurance carriers we are offering you coverage with ?  YesNo

16. During the last five years has any applicant been indicted for or convicted of an degree of the crime of fraud, bribery, arson or any other arson-related crime in

connection with this or any other property?  YesNo

17.  Any bankruptcies. tax or credit liens against the applicant in the past five (5) years? Yes No

18. Has any of your business interest been placed in a trust? Yes No  ( If "Yes" Name Trust In Comments Below )

 

 If you answered " Yes " to 1 through 18 above please indicate question # and briefly explain below:

 

 

 Comments/Remarks:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage.  To confirm binding or current policy revisions you must receive a written confirmation for any  new or change in coverage from our agency staff.

Submitting Agent/ Producer  - Name: Tel: Email:

 

       

 

 

Click Here To View Glossary of Auto Insurance Terms

Auto insurance pays for damages, injuries, and other losses that are detailed in your policy. Depending on the type of coverage, auto insurance can either pay for your damages or another driver’s damages, or a passengers damages.

The most common types of auto insurance are:

LIABILITY pays for damage caused by you to another person or another person's vehicle or other property as a result of an automobile accident. Types of liability coverage include:

 

bulletBodily Injury (BI) If you injure someone in an auto accident for which you are legally to blame, this coverage will pay claims for injury or death against you and the cost of legal defense.

Please keep in mind that you are responsible for any amount of a covered loss that exceeds the amount of insurance coverage you purchase; therefore we highly recommend you consider securing higher limits of bodily insured auto liability coverage to protect your personal assets in the event of a large liability settlement or a count renders a judgment for a dollar amount that exceeds your policy limits. We would highly recommend you request a quote for a Personal Umbrella Liability Policy as recent court judgments to claimants for wrongful death , pain & suffering due to injuries , medical expenses , and/or loss of income due to a negligence of another party have been substantial.

 

bullet Property damage (PD) pays for damage that you cause to someone else's vehicle or property for which you are legally liable. This does not cover your car or property.

Please keep in mind that you are responsible for any amount of a covered loss that exceeds the amount of insurance coverage you purchase; therefore we highly recommend you consider securing higher limits of property coverage to protect your personal assets in the event of a large liability settlement or a court renders a judgment for a dollar amount that exceeds your auto property damage policy limits due damages you cause to someone else's property. Accidents involving multiple automobiles, high valued automobiles, or commercial vehicles may result in substantial losses that exceed coverage limits available under a standard Texas auto policy so we would highly recommend you request a quote for a personal Umbrella Liability Coverage.

 

bullet Medical payments pays for medical, hospital or funeral expenses for you and others injured or killed while riding in your car, regardless of fault. It also covers you and family members if struck by a car as a pedestrian or if riding in another car.

PHYSICAL DAMAGE pays for a loss resulting from damage to your vehicle or a vehicle operated by you. Physical damage also provides coverage if your vehicle is stolen. Types of physical damage coverage include:

 

bullet Collision pays for damage to your car from an accident regardless of fault. It usually includes a deductible and the insurance company pays the rest. Selecting a larger deductible can lower your collision premium.

 

bulletOther Than Collision (Comprehensive) pays for damage to your car caused by most anything other than a collision. Glass breakage, theft, fire, explosion, impact with an animal, vandalism and flood are some of these hazards. This coverage is also available with deductibles to lower your premium.

OTHER COVERAGE Other types of auto coverage include:

 

bullet Uninsured Motorists (UM) Unfortunately, not everyone purchases auto insurance. If you or your passengers are injured by someone who does not carry auto insurance, UM coverage will pay for injuries up to your policy limits. This includes medical expenses, loss of wages, and related expenses. UM coverage also applies if you are a victim of a hit-and-run driver.

 

bullet Underinsured Motorists (UIM) Just as some drivers don't carry any auto insurance, other's don't carry enough to pay for damages from their accidents. UIM coverage pays for death and injury expenses to you or occupants of your car when the other person's insurance is inadequate.

 

bullet Personal Injury Protection (PIP)) Coverage pays for medical expenses and 80% of lost income, regardless of who is at fault in the accident. It also pays for assistance with personal services you are unable to perform because of an auto accident. You, your family members, and your injured passengers are covered under PIP. Insurance; insurance companies must offer to sell you PIP coverage (and Uninsured Motorist Coverage) along with your liability coverage. If you decide not to purchase PIP, you must reject it in writing. PIP coverage is available at limits of $2500 and up.

 

bullet

 

Rental Reimbursement pays for the cost to rent an automobile up to the daily and total maximum amount of coverage you purchase ;up to your available policy limits;  while your vehicle is being repaired or replaced should a total loss occur from damage or theft.

 

bullet

 

Towing pays for the cost have your vehicle towed to a repair shop ; up to your per select policy limit; by a wrecker service should you automobile be damaged under your policy for a covered loss.

 

2007 Automobile Underwriting Guidelines

What is an underwriting guideline?

An “underwriting guideline" is a rule, standard, guideline, or practice, whether written, oral, or electronic, that is used by an insurance company (or its agent) to decide whether to accept or reject an application for a personal automobile insurance policy or to determine what rate will apply to an applicant once the application is accepted.

To view the 2007 Automobile Insurance Underwriting Guidelines in PDF format please CLICK HERE
 
In order to the PDF you will need the free version of Adobe Acrobat.