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TRUCKER QUOTE
Please enable JavaScript in your browser to complete this form.
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Step
1
of 4
COMPANY INFORMATION
Business Name or Insured Name
*
Type of Business (Sole Proprietor, LLC, INC)
*
EIN or SS
*
Email
*
Phone
*
Date Business Started
*
What does your business do? Please be detailed
Location Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address if applicable
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
CONTACT INFORMATION
Owner Name
*
First
Last
Date of Birth
*
Phone
*
Duties of the owner
*
Payroll of the owner (Yearly)
*
Does this owner own 100% of the business?
*
Yes
No
If not, what percentage does this owner hold in the company
Inspection Contact
Phone
Accounting Contact
Phone
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
Continue
EMPLOYEE INFORMATION
Other Employee Information
Employee Name
First
Last
Date of Birth
Title
Duties
Annual Payroll
Ownership Percentage
Upload additional employees
Click or drag a file to this area to upload.
Include name, Date of Birth, Duties, and annual payroll
Do you have Prior Worker's Compensation Insurance?
*
No
Yes
Any claims?
No
Yes
Name of prior insurer if applicable
Expiration Date
Upload Loss Runs if available
Click or drag a file to this area to upload.
Upload 3 years loss runs if you have prior insurance
Next
COVERAGES
Effective Date
*
Employer Liability Per Accident
$100,000
$500,000
$1,000,000
Other
Employer Liability Per Policy
$500,000
$500,000
$1,000,000
Other
Employer Liability Per Employee
$100,000
$500,000
$1,000,000
Other
UNDERWRITING (EXPLAIN ALL YES RESPONSES)
DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?
*
No
Yes
DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (E.G. LANDFILLS, WASTES, FUEL TANKS, ETC)
*
No
Yes
ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
*
No
Yes
ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER? all DOT Regulations?
*
No
Yes
IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
*
No
Yes
ARE SUB-CONTRACTORS USED? (IF “YES”, GIVE % OF WORK SUBCONTRACTED)
*
No
Yes
ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (IF “YES”, PAYROLL FOR THIS WORK MUST BE INCLUDED IN THE STATE RATING WORKSHEET ON PAGE 2)
*
No
Yes
IS A WRITTEN SAFETY PROGRAM IN OPERATION?
*
No
Yes
ANY GROUP TRANSPORTATION PROVIDED?
*
No
Yes
ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
*
No
Yes
ANY SEASONAL EMPLOYEES?
*
No
Yes
IS THERE ANY VOLUNTEER OR DONATED LABOR? (IF “YES”, PLEASE SPECIFY)
*
No
Yes
ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
*
No
Yes
DO EMPLOYEES TRAVEL OUT OF STATE? (IF “YES”, INDICATE STATE(S) OF TRAVEL AND FREQUENCY)
*
No
Yes
ARE ATHLETIC TEAMS SPONSORED?
*
No
Yes
ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
*
No
Yes
ANY OTHER INSURANCE WITH THIS INSURER?
*
No
Yes
ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED IN THE LAST THREE (3) YEARS? (NOT APPLICABLE IN MO)
*
No
Yes
ARE EMPLOYEE HEALTH PLANS PROVIDED?
*
No
Yes
DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
*
No
Yes
DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
*
No
Yes
DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? IF “YES”, LIST OF EMPLOYEES BELOW
*
No
Yes
ANY TAX LIENS OF BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (IF “YES”, PLEASE SPECIFY)
*
No
Yes
ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).
*
No
Yes
Provide other helpful details below or all yes responses above.
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.
Submit