Trucking Insurance

Truck Insurance Quote Form

Insurance Quote Request
Doing Business As *
Number of Partners/Owners
Legal Entity
Phone Number*
Business Description
Business Owner
Address1*
Address2
City
State
E-mail*
Effective date for policy*
Tax ID or Social Security Number

State:

 

 

DOT #:

DMV #:

Zip Code:

Radius:

Cargo Maximum Radius: 

 

AL Limit:

Pollution: 

 

Cargo Limit:

 

Trailer Interchange:

No

Yes

 

 

 

Limit Per Unit

 

 

 

Deductible Required

 

 

 

No

Yes

 

Current Signed Agreement with UIIA

 

 

 

 

NOT available without a valid equipment or interchange agreement

 

 

 

 

 

 

Cargo Filings Required:

How many?: 

 

Commodity :

%

 

 

 

 

Commodities must total 100%

 

 

 

 

 

 

Are you hauling any of the following commodities: Automobiles, Boats, Explosives, Machinery, Mobile Homes,
Oilfield Equipment, Pharmaceuticals, Seafood, Metal Coils?

No

Yes

 

 

 

Years In Business :

   

Driver


Driver Name:
DOB:
(MMDDYY)
Experience (Years)
Similar Equipment
Experience (Years)
Cdl License
# Of At Fault
Accidents:
# Of Minor
Violations:
List Of Major
Violations:
   

Vehicles

  Type: Model year: Model: Serial number: Pd deductible: Vehicle value:  
Unit :  

 

Optional Coverages


 
Hired Auto No Yes Cost of Hire  
Non-ownership liability : No Yes  
Increased uninsured/underinsured motorists: No Yes Additional Premium Limit
Greater than basic pip: No Yes Additional Premium PIP Option
Additional Insured: No Yes Additional Premium
Additional Comments
Description of Operations