Transportation Insurance Quoting Information

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Salesperson

Insured

Entity Type

DOT Number

The "DOT Number" issued by the Federal Motor Carrier Safety Administration

Insured Name (Entity)

Doing Business As ("DBA")

Owner's Name

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Garaging Address (If Applicable)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insured Contact Info

Name

First Last

Phone

Operations

Data Sharing Options

None

ELD Only (Save $300/vehicle)

Dash Camera (+$300/vehicle)

Has your prior insurance ever been cancelled or non-renewed by any insurer in the past 3 years (for any reasons NOT related to payment of premium)

Yes

Any bankruptcies (Chapter 11, 7, or 13) in the past 5 years?

Yes

Time operating in your name (# Years + # of additional months)

Additional Months

Best description of your operation - Choose any that apply:

Local Trucker

Intermediate Trucker

Long Haul Trucker

Intermodal or Port

Hot Shot

Dump Trucks (Other)

Dump Trucks (Sand and Gravel)

End Dumper Units

Logging

Refrigerated Trailer

Oversized or Overweight

Automobile Hauler

Household Goods Mover

Tankers

UIIA - Intermodal

Towing

Taxi / Limousine Service

Cement Mixer

Other (Enter Below)

Best Description of your operation (Other)

Will there be any personal use of any vehicle(s)?

Yes

Radius

Enter the percentage of your hauls that fall in to each distance range for the fields below.

% of Hauls up to 50 Miles (Please enter a number from 0 to 100)

% of Hauls 51-200 Miles (Please enter a number from 0 to 100)

% of Hauls 201-500 Miles (Please enter a number from 0 to 100)

% of Hauls over 500 Miles (Please enter a number from 0 to 100)

Cargo

Use the 'Add Cargo' button below to add all of your cargo types to the list below.

Value of Limit-Motor Truck Cargo

Cargo

Cargo	Percent of Total Cargo (Enter a number from 1 to 100)	Actions
There are no Cargos.

Maximum number of cargos reached.

Refrigeration

Yes Refrigerated Goods Hauled

No Refrigerated Goods Hauled

Terminals

Use the 'Add Terminal' button below to add all of your terminals to the list below.

Terminals

Terminal Address	Actions
There are no Terminals.

Maximum number of terminals reached.

Vehicles

Use the 'Add Vehicle' button below to add all of your vehicles to the list below.

Vehicles

Vehicle VIN	Year	Make or Manufacturer	Model	Value $	Class	Body Type	Actions
There are no Vehicles.

Maximum number of vehicles reached.

Trailers

Use the 'Add Trailer' button below to add all of your trailers to the list below.

Trailers

Trailer VIN	Year	Make or Manufacturer	Model	Value $	Body Type	Actions
There are no Trailers.

Maximum number of trailers reached.

Drivers

Use the 'Add Driver' button below to add all of your drivers to the list below.

Drivers

Driver Name	License State	License Number	Driver Date of Birth	Driver Date of Hire	Experience on Equipment (# of years + # of additional months)	Additional Months	Driver Eligibility	Number of Accidents	Number of Violations	Number of Suspensions	Number of Major Violations	Actions
There are no Drivers.

Maximum number of drivers reached.

To expedite your Proposal, we need the following:

Loss History for the Past Five Years*

Max. file size: 128 MB.

*We need this to provide discounts, and for Underwriting approval. Claims History – aka “loss runs” are ordered by you from your current Agent and/or Insurance Company. It is a good business practice to order these yearly. Loss History is only provided to Owner / Property Manager, we do not have access or authority to request.

Copy of your IFTA report

Max. file size: 128 MB.

Copies of your Commercial Auto, General Liability and Umbrella Coverages, if any.

Max. file size: 128 MB.

Consent(Required)

I Agree to the Privacy Policy, Terms of Service, and to Receive Communications.

Name

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