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North Carolina and South Carolina Businesses Only!

Let us quote your Trucking Insurance needs! You may give us a call or complete the following form to receive a competitive quote.



Contact Information...
Name (required)
Address
Address (second line)
City
State
Zip

Please Contact Me Via...
Phone E-Mail Fax
Work Phone
Best Time To Call
Home Phone
Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company
(not agency)
Date Current Policy Expires
mm/dd/yyyy

Your Equipment...
Unit
Year
Make Body Style VIN
Vehicle Identification #
Gross Vehicle Weight Unit Value
1
2
3
4

Your Drivers
Driver Name State Number of Years with CDL
1
2
3
4

General Questions
Has this business ever operated under any other name? Y N
Are any oversize/overweight filings required? Y N
Are any tandem or twin trailers ever used? Y N
Are any hazardous commodities hauled? Y N
Do you haul containerized freight? Y N
If yes, are only specialized container chassis used?
Y N
Are vehicles used for wholesale or retail delivery? Y N
Are drivers accompanied by a helper or second driver? Y N
Do you maintain a formal safety program? Y N
Do you ever allow relatives or others to ride? Y N
Are you complying with DOT regulations? Y N
Maximum radius operated by any vehicle? (miles)
If the radius is over 200 miles list the major cities traveled through.
What is the maximum number of hours your drivers will operate a vehicle within a 24-hour period? (hours)
How many new drivers did you employ in the last year? (drivers)
ICC or State Filing required? Y N
If yes, enter the name as it exactly appears on the
filing with the MC docket #, if applicable.

Cargo Insurance
List specific commodities and percentages hauled of each. (No general terms)
Commodity Name (Type) Percentage Average $ Value Max $ Value
% $ $
% $ $
% $ $
% $ $

Cargo Insurance Requested
Making a request does NOT mean that you are insured. You are not covered until you receive notification from our office.
Limits Desired if other specify
Deductible

General Information
Current Insurance Company:
Any losses? Y N
If yes, please explain
Years in business:


This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.


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