Business Insurance
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Small Fleet Transportation Quote

This form is to be used for companies looking to insure fleets of 5 or fewer trucks. For larger fleets, please use our large-fleet trucking form.

A star (*) indicates required questions.

Contact Information
* First Name:
* Last Name:
Title:
* Company:
* Address:
* Email Address: Example: “user@example.com”
* Phone Number: Example: “414-555-1234”
Coverage

  1. * Desired effective date:

    (MM/DD/YYYY)

  2. * Number of years primary liability coverage under above name:

  3. If non-trucking liability, enter the name of company leased to.

Fleet Information

  1. * US DOT Number:

  2. Is there broker authority under this FMCSA #?

    If Yes, enter MC#:

  3. Commodities hauled:

  4. States entered:

  5. Major cities:

  6. Has risk been cancelled or non-renewed in last 3 years?

  7. Is risk covered by Workers’ Compensation?

  8. How many years has the insured owned commercial equipment?

  9. Filings Needed:

    If Yes, FMCSA Docked #:

  10. FEIN or SSN #:

  11. Do you pull:

Driver Information
1.
Last 3 years - Number of:
2.
Last 3 years - Number of:
3.
Last 3 years - Number of:
4.
Last 3 years - Number of:
5.
Last 3 years - Number of:
Vehicle Information
1.
2.
3.
4.
5.
Loss Information

Previous Carrier & Loss information – must show current year and previous 2 years. If previous leased to another company, list that company.

1.
2.
3.
4.
5.
Coverage & Limits
Liability – Please choose an option:
Auto Liability Limit:
Uninsured Motorist Limit:
Underinsured Motorist Limit:
Personal Injury Protection Limit:
Medical Payments:
Hired Auto:
Liability:
Physical Damage:
Cargo:
Trailer Interchange:
Other:
Type:
Amount:
Physical Damage:
Desired Deductable:
Collision: $
Other than Collision: $
Cargo
Commodity Transported % of total revenue Value per truck load
Maximum Average
Desired Options:
Cargo Limit: $
Cargo Deductible(s) $
Reefer Deductible(s) $

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.

Last modified on August 30, 2007 at 11:36:47 AM