Trucking Quote

North Carolina, South Carolina, Tennesse,
Virginia, Georgia, Florida, Mississipi,
California, Louisiana, Alabama, West Virginia,
and Texas Businesses Only!

Contact Information...
Name (required)
Address
Address (second line)
City		State	Zip

Please Contact Me Via...	Phone E-Mail Fax
Work Phone		Best Time To Call
Home Phone		Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

Unit	Year	Make	Body Style	VIN Vehicle Identification #	Gross Vehicle Weight	Unit Value
Your Equipment...
1
2
3
4

Driver	Name	Driver's License #	State	Number of Years with CDL
Your Drivers
1
2
3
4

General Questions
Has this business ever operated under any other name?	Y N
Are any oversize/overweight filings required?	Y N
Are any tandem or twin trailers ever used?	Y N
Are any hazardous commodities hauled?	Y N
Do you haul containerized freight?	Y N
If yes, are only specialized container chassis used?	Y N
Are vehicles used for wholesale or retail delivery?	Y N
Are drivers accompanied by a helper or second driver?	Y N
Do you maintain a formal safety program?	Y N
Do you ever allow relatives or others to ride?	Y N
Are you complying with DOT regulations?	Y N
Maximum radius operated by any vehicle?	(miles)
If the radius is over 200 miles list the major cities traveled through.
What is the maximum number of hours your drivers will operate a vehicle within a 24-hour period?	(hours)
How many new drivers did you employ in the last year?	(drivers)
ICC or State Filing required?	Y N
If yes, enter the name as it exactly appears on the filing with the MC docket #, if applicable.

Commodity Name (Type)	Percentage	Average $ Value	Max $ Value
Cargo Insurance List specific commodities and percentages hauled of each. (No general terms)
	%	$	$
	%	$	$
	%	$	$
	%	$	$

Cargo Insurance Requested Making a request does NOT mean that you are insured. You are not covered until you receive notification from our office.
Limits Desired	if other specify
Deductible

General Information
Current Insurance Company:
Any losses?	Y N
If yes, please explain
Years in business:

Comments, Questions, or Additional Information

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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