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Truck Quote Form

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Quote Target Date:

Renewal Date:

Contact Person:

DBA Name:

MC #:

Legal Name:

Phone #:

Email Address:

Fax #:

Mailing Address:

City:

State:

Zip:

Garaging Address:

City:

State:

Zip:

Describe in detail items being hauled/carried

LIST OF TRUCKS AND TRAILERS( Attach List if Available)

Year:

Make:

Current Value:

Comments:

Year:

Make:

Current Value:

Comments:

Year:

Make:

Current Value:

Comments:

Year:

Make:

Current Value:

Comments:

Year:

Make:

Current Value:

Comments:

Year:

Make:

Current Value:

Comments:

Accident Details /At Fault & NOT At Fault

Driver(S) Name:

DL#:

#of Years Class A License:

Commercial or Personal:

Driver(S) Name:

DL#:

#of Years Class A License:

Commercial or Personal:

Driver(S) Name:

DL#:

#of Years Class A License:

Commercial or Personal:

PRIOR INSURANCE INFORMATIONYEARS WITH CURRENT CARRIER (List last 4 years of insurance providers)

Current Year

Effective Dates:

Complete Company Names:

# of Losses:

Paid Out/Open Claims:

Policy #:

Year 2

Effective Dates:

Complete Company Names:

# of Losses:

Paid Out/Open Claims:

Policy #:

Year 3

Effective Dates:

Complete Company Names:

# of Losses:

Paid Out/Open Claims:

Policy #:

Year 4

Effective Dates:

Complete Company Names:

# of Losses:

Paid Out/Open Claims:

Policy #:

COVERAGE LIMITS

Liability Limits (min $750,000)

Physical Damage Deductible:

Cargo Limit:

Expiring Premium:

Installment Amount:

# of Installments:

GENERAL LIABILITY :

WORKERS’ COMP

Employee Federal Tax ID #:

# of Employees:

Duties:

Annual Payroll:

Comments: