J. Van Financial Group, PLLC.

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Trucking Quote

Trucking Insurance Quote

Contact Name:

Day Telephone:

Business Name:

Eve Telephone:

Street Address:

Fax:

City, State Zip:

Best Time To Reach You:

E-Mail Address:

Company Information

Number of Years in Business

Effective Date Requested for Insurance

Are you permanently leased to a FHWA licensed carrier (bobtail coverage)?
Yes No

For Hire FHWA Licensed Motor Carrier? (Do you haul under your own authority?)
Yes No

If Yes - MC Number DOT Number

	Commodities Hauled	%
1.
2.
3.
4.
	Total	100%

Tractors, Trailers & Straight Trucks

Type	Year	Make or Brand	Physical damage coverage?	Radius of Operation
1
Enter Stated Value: $			VIN #
2
Enter Stated Value: $			VIN #
3
Enter Stated Value: $			VIN #
4
Enter Stated Value: $			VIN #
5
Enter Stated Value: $			VIN #
6
Enter Stated Value: $			VIN #
7
Enter Stated Value: $			VIN #
8
Enter Stated Value: $			VIN #
9
Enter Stated Value: $			VIN #
10
Enter Stated Value: $			VIN #
Check here if you have more than 10 Trucks, Tractors, or Straight Trucks; we will contact you for additional information.

Drivers (Including Owner-Operators)

Name of Driver #1	License Number	License State	Years Experience	Date of Birth
1
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
1
Name of Driver #2	License Number	License State	Years Experience	Date of Birth
2
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
2
Name of Driver #3	License Number	License State	Years Experience	Date of Birth
3
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
3
Name of Driver #4	License Number	License State	Years Experience	Date of Birth
4
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
4
Name of Driver #5	License Number	License State	Years Experience	Date of Birth
5
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
5
Check here if you have more than 5 Drivers; we will contact you for additional information.
Please explain any moving violations (date and type) and give dates of any accidents in the box below.

Coverages Required

Bobtail (non trucking liability) Yes No

Occupational Accident Coverage Yes No

Primary Liability Insurance
(maximum 1,000,000) yes no Limit

Cargo Insurance Yes No

Limit

Deductable

Refrigeration Breakdown Coverage Yes No

Do you need to insure someone else�s trailer? yes no

Enter Limit

General Liability Insurance yes no

Total Payroll Amount

Total Driver Payroll Amount

Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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