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Trucking Insurance Intake Form
Company information
Company Name
*
DBA (if different)
DOT Number
*
MC Number (if applicable)
Company address
Street Address
*
Address Line 2
City
*
State
*
Zip Code
*
Country
*
Company information
Years in Business
*
Number of Trucks
*
Contact information
Contact First Name
*
Contact Last Name
*
Contact Email
*
Contact Phone
*
Contact Company Name (if different)
Role in Company
*
Please select
Owner
Manager
Driver
Administrator
Other
Operations
Type of Operation
*
Please select
Long Haul
Short Haul
Local Delivery
Regional
Specialized
Mixed
Commodities Hauled
*
General Freight
Household Goods
Heavy Machinery
Building Materials
Hazardous Materials
Refrigerated Goods
Other
Other Commodity
Operating Radius
*
Please select
Local (0-50 miles)
Intermediate (51-200 miles)
Long Distance (201+ miles)
Interstate
National
States of Operation
*
Vehicles
Vehicle Types
*
Tractor-Trailer
Straight Truck
Box Truck
Dump Truck
Flatbed
Tank Truck
Other
Other Vehicle Type
Vehicle List File
Vehicle List
Drivers
Number of Drivers
*
Average Driver Experience
*
Please select
Less than 1 year
1-3 years
4-6 years
7-10 years
More than 10 years
Driver List File
Driver List
Current insurance and claims
Current Insurance Carrier (if any)
Current Annual Premium (if applicable)
Current Policy Expiration Date
Claims History (Last 3 Years)
*
Yes, we've had claims
No, we haven't had any claims
Claims Details
Loss Runs Documentation
Coverage requested
Coverage Types Needed
*
Auto Liability
Physical Damage
Cargo Insurance
General Liability
Umbrella/Excess
Workers Compensation
Other
Other Coverage Type
Desired Liability Limit
*
Please select
$750,000
$1,000,000
$2,000,000
$5,000,000
Other
Desired Cargo Limit (if applicable)
Please select
$100,000
$250,000
$500,000
$1,000,000
Other
Additional information
Any Additional Information
How did you hear about us?
Please select
Internet Search
Referral
Social Media
Industry Event
Advertisement
Other
Authorization
Information Authorization
*
I acknowledge that the information provided is accurate to the best of my knowledge and authorize the insurance company to verify it for the purpose of providing an insurance quote.
Thank you. Your trucking insurance application has been submitted.
Submit Trucking Insurance Application
