commercial ins quote

Customer Name

E-mail

Company Name

Cell Phone

Best time to call

D/B/A Name

Send quote by:

Fax

Phone

Street:

GARAGE ADDRESS

Report the prior three year history for each driver. When reporting violations, you should be specific as possible about the each violation. For example: If for speeding: 14 mile over the limit.

(Where you park your truck)

City:

State:

Zip Code:

COVERAGE NEEDED

Primary Coverage

Liability

Physical Damage

Cargo

Non-Trucking (Bobtail) and Physical Damage

LIABILITY LIMITS

Amount:

Other:

ICC / FHWA FILINGS

MC Number:

DOT numberr:

TRAVEL INFORMATION

Radius:

(Furthest destination traveled)

States Traveled:

Cities Traveled:

CARGO LIMITS

Amount:

Other:

(Most shippers will require a $100,000 limit)

COMMODITIES

Commodities

%

Value of Avg. Load

Max value of Load

1.

2.

3.

4.

COMPANY HISTORY

Prior three year insurance carrier history. If you did not have insurance in your name, please indicate the companies that were leased on, or companies for which you were a driver.

Dates

Insurance Company

Year 1.

Year 2.

Year 3.

Claims/Losses

Policy Amount

Years In Business:

Current Policy Expiration date:

VEHICLE SCHEDULE

#5.

Year

Make/Model

GVW

Value

#6.

#7.

#4.

#3.

#2.

#8.

#1.

#9.

DRIVER SCHEDULE

Driver name (from CDL)

DOB

Yrs w / CDL

# of Violations

#1.

#2.

#3.

#4.

#5.

#6.

#7.

#8.

#9.

Date of hire

How did you find us?

TTX Insurance Consultants, Inc.

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