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Truckers Quote Form

Please fill out this quote form to the best of your knowledge, and we will contact your for more information if needed.

*Corporate or Individual Name (Include DBA): FEIN/ Tax ID
Physical Address:
*Contact: *Phone: Email:
Need Federal Filing / BOC-3? Yes No DOT#: MC#:
Fully describe your operation include the products and commodities hauled:
Current Insurance? Yes NoDate coverage is being requested:
Ins. Company: Expiration Date: Type of Ins.:
Ins. Company: Expiration Date: Type of Ins.:

Coverage & Limits Requested – All Quotations will be for Specified Autos only – Check all that apply

AUTO LIABILITY
$60,000 CSL$25/$50/$10
$100,000 CSL$50/$100/$25
$300,000 CSL$100/$300/$50
$500,000 CSL$250/$50/$100
$750,000 CSLOther
$1 Million CSL$
Hired/Non-Owned
PHYSICAL DAMAGE
Comprehensive $ (ded.)
Collision $ (ded.)
Downtime/Rental$
Roadside Assistance$
Tow Truck on Hook$
Medical Payments$
Un/Under Insured$
Tow Truck on Hook$
NON-TRUCKING LIABILITY
$1M/2M
TRAILER INTERCHANGE
Fire & Theft $ (ded.)
Fire/Theft/Collision $ (ded.)
Comp/Collision $ (ded.)
MOTOR TRUCK CARGO
$50,000Cargo Deductible:
$100,000$500
$150,000$1,000
$200,000$2,500
$250,000
List All Cargo:
Cargo coverage at a terminal for vehicles left even if overnight or weekends.

*Provide addresses on notes section

OTHER INSURANCE

SCHEDULE OF VEHICLES – List all Vehicles to be quoted.

State of registrationYearMakeVINWho’s Name is vehicle registered underValueGross Weight

DRIVERS INFORMATION:

NameD.O.BCDL License #/State

Notes:

FYI: To obtain a cargo quote we will need driving records not older than 30 days for all listed drivers. Also, please obtain from your current agent a 3-year claim history (loss runs).