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Transportation Insurance Quote Questionnaire
Call Us Today At
(281) 550-5864
Transportation Insurance Quote Questionnaire
Legal Name of Business
DBA
Owner Name
Main Contact Name
Fed Tax I.D.
Legal Entity
Individual / Sole Proprietor
Corporation
Partnership
Limited Liability
Physical Address (Street, City, State, ZIP)
Mailing Address (Street, City, State, ZIP)
Garaging Address (Street, City, State, ZIP)
Phone
Fax
Email
Years in Business
Estimated Annual Payroll
# of Employees
Estimated Annual Revenue
MC#
US DOT#
TX DMV#
Detailed Description of Business
What Are Your Primary Traffic Routes
From (City & State)
To (City & State)
Total Miles
Radius of Operation in Miles
50-100
101-300
300-500
500-1000
1000 Plus
Regular and Frequent Use in Confined to a Radius of How Many Miles?
Estimated Annual Miles Driven
Areas of Operation (%)
Northwest
Southwest
Midwest
Northeast
West
East
Texas
Commodities Hauled
Specific Commodity
Percentage % of Total
$ Value
Any Hazmat?
Yes
No
If Yes, state materials being hauled in detail
Additional Comments
Requested Coverages & Limits Section
Please check requested coverages and their limits below.
Auto Liability
$500,000
$750,000
$1,000,000
Hired / Nonowned Auto
$1,000,000
$2,000,000
Uninsured / Underinsured Liability
$250,000
$500,000
$750,000
$1,000,000
Physical Damage Deductible
$500 Deductible
$1000 Deductible
$2500 Deductible
$5000 Deductible
Motor Truck Cargo
$50,000
$100,000
$150,000
$200,000
$250,000
$500,000
Excess Cargo
$250,000
$500,000
$1,000,000
$2,000,000
Commercial General Liability
$1,000,000
$5,000,000
Workers Comp
Trailer Interchange
$15,000
$20,000
$30,000
$40,000
$50,000
Other
Additional Information
Insurance Carrier Section
Who is your current insurance carrier?
What is your current monthly insurance payment?
What is your total annual premium?
What is the expiration date of your current policy?
Is your current carrier offering a renewal?
Yes
No
If your current carrier is not offering a renewal, please state reason in detail:
Has your policy cancelled or non-renewed in the prior 3 years?
Yes
No
If policy cancelled or non renewed, please give reason in detail
Loss / Claim History
Insurance Company
Description of Loss/Claim
Type of Loss/Claim
Date of Loss/Claim
Open or Closed
$ Value
Additional Comments
3 Years of Work History (If Business is Under 2 Years)
Company Name
Length of Employment
Description of Duties & Position
Additional Comments
Drivers
Name
DOB
CDL#
State
Driver Activity (Tickets, Accidents, Claims)
Years w/ CDL
Date Hired
Additional Comments
Vehicles
VIN
Year
Make & Model
Owner
Tractor Type
Gross Weight
$ Value
Trailers
VIN
Year
Make & Model
Type
Owner
$ Value
Additional Comments
Do you have any owned, leased or operated equipment not listed on the vehicle schedule?
Yes
No
Are any of your owned, vehicles loaned or rented to others?
Yes
No
Have you had any bad inspections in the past year?
Yes
No
If YES, please state reason in detail
If YES, please state reason in detail
If YES, please state reason in detail
Applicant's Name
Title
Today's Date
Signature
*
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