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

  

PLEASE NOTE: Any fields marked with a red asterisk (*) are REQUIRED and must be filled in for your quote request to be processed as quickly as possible.

 CONTACT INFORMATION

Truck Owner Operator - Named  Insured 

Name:

  DBA:

Address:

City
State

    Zip Code

Tel.

Mobile / Cell

Main Office Tel.
Email:

  

Primary Location For  Garaging Vehicles:

OPERATION INFORMATION

*Description of operations:
Is insured hauling for hire? Yes No
If no, please explain:


*Major cities traveled from or to, if 10% or more:

 *Requested Effective Date For  New Coverage :   

*Current annual revenue:

Projected Revenue Next 12 Months:

*Current annual mileage:

Projected Mileage Next 12 Months:

*USDOT/MC #:

*TXDOT#:

Employer Federal Tax Id #     (if applicable)

Individual Owner Operator - Social Security #

*Years in business?
Years owning your own equipment?

Sand & gravel? Yes No
If yes, belly or end? Belly End

Name of Current Insurer Policy Number  

Policy Expiration Date Approximate Annual Premiums

*Operating primarily on fixed routes to regular destinations? If yes, please list destinations, including percentages, for each city/state below. Yes No

*% of loads received through:
Brokers:    Shippers:

Destination City, State

%

Destination City, State

%

Destination City, State

%

1.

2.

3.

4.

5.

6.

7.

8.

9.

 DRIVER INFORMATION
*ALL fields must be completed for each driver and the owner!

Name

Driver License #

State

DOB

Hire Date

Years Exper.

Violations/Accidents

1.

2.

3.

4.

5.

Owner's complete information, if individual owner not listed above - even through  such owner may not operate any vehicles.

6.

VEHICLE INFORMATION

Year

Make / Type / Model

Vehicle ID Number

 

( This is a 17 Digit Number)

Current Vehicle Value

Weight / Radius / Miles / Hitch

Type Usage

1. 

 

 

2. 

 

 

3. 

 

 

4. 

 

 

5  .

 

 

 

 

6. 

 

7. 

 

8  .

 

 

9. 

 

 

10.

 

*Number of power units operated in the last year:

INSURANCE CARRIER AND LOSS INFORMATION (Past Three Years)
*ALL fields must be completed for each policy!

If leased prior, please indicate number of years:

Policy Dates

Company

Policy #

Loss Info

From:
To:     

From:
To:     

From:
To:     

COVERAGE(S) AND LIMITS

Commercial Truck Insurance Coverage Limits

Cargo Insurance Coverage Limits

Primary                Non-Trucking

Auto Liability Limit:

Uninsured Motorist:

Accept Reject

Pers. Injury Protection:

Accept Reject

Medical Payment:

Accept Reject

Hired / Non-owned Auto:

Accept Reject

Trailer Interchange:

Physical Damage Deductible:

Comp & Coll? Yes No

General Liability Limit:

Current In ForceYes No

 

 Occurence
 

 Aggregate

 

Limit:

Ded:

Reefer Breakdown Coverage:
Yes No

 

Type Commodities Transported

%

Value Per Truckload

Average  

Maximum

 

Additional Vehicles:

Additional Coverage(s) Quotes Requested :

Workers Compensation Insurance  Health / Life / Dental / Vision  Insurance  Group Individual
General Liability Insurance

Business Owners Policy 

 Package Policy / Building / Contents /

Business Interruption (Loss of Income- Extra Expense) / Liability

Umbrella Liability   Flood ( Commercial Property )
Cargo ( Inland or Marine )

Other - Please specify or describe below:

 

7. COMMENTS

Submitting Agent/ Producer  - Name: Tel: Email:

 

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