Trucker Quote Request - Zumach Insurance Agency

CONTACT INFORMATION

Owner Name *

Date of Birth *

Email *

Phone *

Does Owner Have CDL? *

Drivers License Number *

State *

Driver Information

Driver 1 *

First

Last

Date of Birth *

Drivers License Number *

State *

First CDL License Date *

Date Of Hire *

Any Violations? Please list *

Driver #2

First

Last

Date Of Birth

Drivers License Number

State

First CDL License Date

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)

Equipment Type *

Vehicle Year *

Make (eg Freightliner) *

Model

Vehicle VIN *

Gross Weight *

Physical Damage desired on this equipment? *

Value *

Loss Payee Name and Address

Equipment Type 2

Vehicle Year

Make (eg Freightliner)

Model

Vehicle VIN

Gross Weight

Physical Damage desired on this equipment ?

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? *

Name of prior insurer

Expiration Date

Any claims? Please upload loss runs *

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
Other

Cargo Liability

$100,000
$150,000
$250,000
Other

Comp/Coll Deductible

$1000
2,500
5000
Other
None

General Liability

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

Additional Coverages *

Choice/Roadside
UM/UIM
Hired Auto
Non Owned
Med Pay
Rental Reimbursement
UIIA
Other-Please provide Details on Paragraph below

OPERATIONS

Type of Business *

Box Truck-Intrastate
Box Truck-Interstate
Dump Truck
Long Haul Trucking-Interstate
Short Haul Trucking-Intrastate
Trash Hauler
Other-Please provide details on the Details Section

Type of Commodities *

Dry Foods
Paper and Paper Products
Plastics
General Freight
Frozen Food (Meat and Chicken) No Seafood
***Refrigerated with Shell Fish (Call)
Other-Please provide Details on Paragraph below

Radius of Operation *

100 Miles (Intrastate Only)
300 Miles (Intrastate Only)
500 Miles
Unlimited

UNDERWRITING

Do you transport any hazardous commodities/waste? *

Do you allow non-employee passengers? *

Do you haul container or containerized freight? *

Do you participate in a drug testing program and obey all DOT Regulations? *

Is there a Vehicle Maintenance program in operation? *

Are all equipment operated under the applicants authority scheduled under this application? *

Do you obtain MVR (Motor VehicleRecord) Verifications? *

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.

Single Line Text

COMPANY INFORMATION

CONTACT INFORMATION

Driver Information

VEHICLE INFORMATION (Upload additional equipments over 2)

COVERAGES

OPERATIONS

UNDERWRITING

Location

Call Us

About us

Why you need an independent agent

Truckers insurance for my MC Number