Commercial Auto Quote - Zumach Insurance Agency

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TRUCKER QUOTE

- Step 1 of 4

COMPANY INFORMATION (Commercial Auto)

Business Name or Insured Name *

EIN or SS *

Effective Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Years In Business *

Number of Vehicles *

Number of Drivers *

CONTACT INFORMATION

Owner Name *

Date of Birth *

Email *

Phone *

Is Owner Licensed? *

Yes
No

Drivers License Number *

State *

Driver Information

Driver 1 *

First

Last

Date of Birth *

Drivers License Number *

State *

Years of Experience *

Date Of Hire *

Any Violations? Please list *

Driver #2

First

Last

Date Of Birth

Drivers License Number

State

Years of Experience

Date Of Hire

Any Violations? Please list 2

Upload Additional Drivers

Click or drag files to this area to upload. You can upload up to 2 files.

Name, Date of Birth, Driver's License, First CDL, and Violations

VEHICLE INFORMATION (Upload additional equipments over 2)

Type of Vehicle *

Light Duty Truck, Minivan, Pickup...

Vehicle Year *

Make *

Model

Vehicle VIN *

Gross Weight

Physical Damage desired? *

Value

Loss Payee Name and Address

Upload additional equipment

Click or drag a file to this area to upload.

Year, Make Model, Type, Value

Do you have Prior insurance? *

No
Yes

Name of prior insurer

Expiration Date

Any claims? Please upload loss runs *

No
Yes

Upload Loss Runs

Click or drag a file to this area to upload.

Upload 3 years loss runs if you have prior insurance

COVERAGES

AutoLiability *

$1,000,000
$750,000
$500,000
$250,000
$100,000
Other
None

Comp/Coll Deductible *

$1000
2,500
5000
Other
None

General Liability *

$1mil/1Mil
$1Mil/2Mil
Other
None

Workers Compensation *

$500.000
$1,000,000
Other
None

Excess Umbrella Liability *

$500.000
$1,000,000
Other
None

Additional Coverages *

Choice/Roadside
UM/UIM
Hired Auto
Non Owned
Med Pay
Rental Reimbursement
None

OPERATIONS

Type of Business *

Type of Tools Used

Owner Payroll (If Workers Comp and GL is Desired)

Payroll (If Workers Comp and GL is Desired)

Radius of Operation *

100 Miles
300 Miles
500 Miles
Unlimited

UNDERWRITING

Do you have emplyees? *

No
Yes

Do you allow non-employee passengers? *

No
Yes

Do you use independent contractors? *

No
Yes

Is there a Vehicle Maintenance program in operation? *

No
Yes

Are all equipment owned scheduled under this application? *

No
Yes

Do you obtain MVR (Motor VehicleRecord) Verifications? *

No
Yes

Provide other helpful details below,

Confirmation (Enter First and Last Name) I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination. *

I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination.

Location

3449B Lawrenceville Suwanee Rd . Suwanee . GA 30024

Call Us

(+1) 678 889 5496

About us

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Truckers Insurance
Business Insurance
Commercial Auto
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