Truck Insurance Quote Form

Applicants Name: Business Name:

Mailing Address: City: ZIP:

Garaging Address: City: ZIP:

Description of commodities hauled: Provide the 4 most common commodities and % of each
% %
% %
Radius: Will applicant be crossing state lines:
(furthest one way distance in miles) If yes, list states entered:

Years Trucking Experience:
How many years prior insurance under the business name listed above?

PRIOR INSURANCE INFORMATION -- *4 years prior continuous coverage can qualify for considerable discounts.
Eff dates (month/year) Company Name # of Losses Paid Out Annual Premium
Current
Year Prior
Year Prior
Year Prior
DRIVERS SCHEDULE If no MVR attached, the MVR activity must section must be complete for indication premium only
*2 years verifiable experience with correct commercial class license if required MVR ACTIVITY LAST 36 MONTHS
Name Class Lic. Date of Birth Yrs Coml Exper. # Moving Viol # Non-Moving viol Major Viol. # Accidents
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Will applicant be hauling under authority of other trucking firm? If yes, provide MC#:

LIABILITY LIMITS CARGO FILINGS
Liability: Medical UM Limit:
$750,000 CSL
$1,000,000 CSL
$1,000
$5,000
$30,000
$60,000
Other: $
Max value per laod
$
Deductible
$
CA#
MC#
DOT#
TRACTOR / POWER UNIT *5+ units require completed app & 3 years loss runs Physical Damage
Year Make - Model Body Type VIN # Stated Value Deductible
1
2
3
4
5
6
7
8
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TRAILER *5+ units require completed app & 3 years loss runs Physical Damage
Year Make - Model Body Type VIN # Stated Value Deductible
1
2
3
4
5
6
7
8
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*If UIIA/UIIE Endorsement Required Please complete the following...
Trailer Interchange Agreement Hired Auto Liability Coverage (select one) Non-owned Auto Liab
Required Trailer Value:
*Refer to applicants Equipment Provider Checklist to confirm value
Cost of Hire: # of Employees:

New Venture Supplement

(Less than 2 years in business)

Applicants Name: Date Coverage Desired:

GENERAL INFORMATION

1. Is owner the only driver? -- If no, question #11 must be fully completed

2. When did you first obtain your commercial class A license? Month Year

3. Have you ever had prior commercial insurance in you or your business name? If yes,
Insurance Carrier: Policy Term(s):

Losses: If yes, Details:

4. Have you been driving trucks / tractors commercially for at least 2 years?
Provide the following previous employer information where employed as a trucker for at least 2 years.

Name Of Prior Employer Contact Name Telephone # Dates Employed (must show a total of at least 2 years)

5. What radius were you traveling while employed?

6. What radius (farthest one way distance) do you anticipate traveling at least 80% of the time?

7. Will you be traveling out of California? If yes,
List states you may travel in: How often?

8. What type of commodities were you hauling while employed?

9. What commodities will you be hauling over the next 12 months?

10. Have you applied or will you be applying for the following authorities?
MCP - State Authority - CA# ICC - Federal Authority - MC#

11. Are there additional drivers that may will be driving or operating vehicles? If yes, provide driver experience for past 2 years.

Drivers Name Name of Prior Employer Contact Name & Tel # Dates Employed (must total 2 years)
(optional):