Transportation & Trucking Quote Form

If you would like to apply for a quote for your transportation or trucking business, please fill out the form below and click "Submit".

Please provide the following contact information:

 Insured Information 
Company Name *
Contact Name
Email *
Address
City
State/Province
Zip/Postal Code
Phone *
Fax
Best time to call
 
 Coverages 
Cargo YesNo
Truck Physical Damage YesNo
General Liability YesNo
Umbrella YesNo
Truck Liability YesNo
Trailer Interchange YesNo
Bob Tail YesNo
Workers Compensation YesNo
Other YesNo
Current Policy Experation Date
 
 Description of Operations 
Description of Operations
 
 Licensed Drivers 
  1. (Primary Driver)
Name on License
License State
License Number
Date of Birth
Years_of_Experience
Tickets and Accidents (last 5 years)
2.
Name on License
License State
License Number
Date of Birth
Years_of_Experience
Tickets and Accidents (last 5 years)
3.
Name on License
License State
License Number
Date of Birth
Years_of_Experience
Tickets and Accidents (last 5 years)
4.
Name on License
License State
License Number
Date of Birth
Years_of_Experience
Tickets and Accidents (last 5 years)
Any additional driver information should be E-mailed to mds@insctrs.com after submission of this form.
 
 Vehicle(s) Information 
  1.
Year
Make
Model
VIN
GVW
Max Radius
2.
Year
Make
Model
VIN
GVW
Max Radius
3.
Year
Make
Model
VIN
GVW
Max Radius
4.
Year
Make
Model
VIN
GVW
Max Radius
Any additional vehicle information should be E-mailed to mds@insctrs.com after submission of this form.
 
 Coverages 
List specific commodities & percentages hauled
Truck Limits Required
Cargo Limits Required
List special items which need coverage
Trailer Interchange Limit Required
Truck Physical Damage Deductible
1.
Cost New
Stated Value
2.
Cost New
Stated Value
3.
Cost New
Stated Value
4.
Cost New
Stated Value
Are there any operations other than trucking? YesNo
If Yes, please explain:
 
 Workers Compensation 
Currently Curried? YesNo
Unassisted lifting over 50 lbs.? YesNo
If Yes, please explain:
Bobtail Limit
List any claims for coverages above. Include date of claim, specific details, and amount paid.
 
List all carriers and policy numbers for any coverages currently carried
1.
Carrier Name
Policy Number
Experation_Date
Type of Coverage
2.
Carrier Name
Policy Number
Experation_Date
Type of Coverage
3.
Carrier Name
Policy Number
Experation_Date
Type of Coverage
4.
Carrier Name
Policy Number
Experation_Date
Type of Coverage
Are there any oversize/overweight filings required? YesNo
Are tandem or twin trailers ever used? YesNo
Are there any hazardous commodities hauled? YesNo
Does the applicant haul containerized freight? YesNo
If yes, are only specialized container chasis used? YesNo
Does applicant hire any new drivers under 23 or over 69? YesNo
Do you ever allow relatives or others to ride? YesNo
If FHWA carrier, please fill in MC#
Max Radius operated by any vehicle
If radius is over 300 miles, list states & cities traveled to or through
Is this a new venture? YesNo
If yes, give prior experience in trucking business
If you selected any options with Other, please specify, explain or elaborate here
* indicates required fields
 
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. (STATE REQUIRED)