Truckers Quote Form

TRUCKING INSURANCE QUOTE REQUEST FORM

Company Name*

Owner*

First NameMiddle NameLast Name

E-mail*

D.O.B.*

MonthDayYear

DOT*

Does owner have CDL License?

YesNo

Loss Payees/Lease?

YesNo

Please enter Name, Full address and Phone number of all Loss Payees.

Contact Person*

First NameLast Name

Contact Phone Number*

Area CodePhone Number

Preferred Language

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Garage Address (Leave blank if same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please remember to click Save/Add to add driver,vehicle and trailer information to the form. By not clicking the Save/Add button, your agent will not receive the information!

List Drivers*

Vehicle Information*

Trailer Information

Does owner or driver have any tickets or accidents in the past 5 Years? If so please include the violations and dates.

Electronic Logs? If yes please list company

Business Type

If Other, please enter below

Other Business Type

Year Established?

Business Operations*

Please describe the nature of your business operations.

Years Experience*

Radius of Operations*

Is this a New Venture?*

When was this Business established?*

Date

If tow truck operation, do you do repos?

Do you Operate in more than one State?*

Which States?

List all States of Operation.

Do you haul hazardous material

Do you operate on a regular route?

Do you rent/lease your vehicles to others?

Do you hire any vehicles?

Currently Insured?

YesNo

Which company?

Please submit any and all Declaration pages/Loss Runs/Logs/motorvehicle records to Kathy@piinsurancegroup.com

Desired Deductible

Cargo Coverage?*

If Yes, please enter amount of coverage below.

Coverage Amount

Do you haul for hire?*

List type of cargo hauled*

Amount of Liability Coverage Required*

Do you need a General Liability Policy?*

Physical Damage coverage?*

Select Comprehensive Deductible *

Select Collision Deductible *

Do you need workers comp?

Select Desired Limit

Please enter Desired Limit

Signature

Prestige International Insurance Group

4740 North Hiatus Rd. Sunrise, FL 33351

754-240-7410

Description of Operations

Type of Insurance Requested