I
haul under my own authority or need my own primary
liability
I
am an Owner/Operator and haul under someone else's
authority
I do not have Federal Authority and only need
State Filings
Type
of Business
Individual
Proprietership
Partnership
Other
Corporation
Tax ID #
Account
Size
1
2
3
4
5
6
7
8
9
10
11
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14
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17
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86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Power Units
Your
MC or DOT Number
If
you have your own authority
Company
or Business Name
Your
Name
Physical Address of Business
City
County
State
Alabama
Georgia
Mississippi
Tennessee
other
states to be added by October 1st
Zip
Code
Office
Phone
Fax #
Home
Phone
Email
Address
Reply
with Quote By
Enter Date
Current
Insurance Expires?
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2003
2004
2005
2006
2007
2008
2009
Commodities Hauled?
Be specific!
Major Cities Traveled Through
Limits
of Auto Liability Needed
$1,000,000
$2,000,000
$750,000
Other
Cargo
Limits Needed
Select One
50,000
$100,000
$250,000
Other
Need
Physical Damage Coverage?
Yes
No
Radius
Traveled
0-300
Miles %
300-1000
Miles %
Over
1000 Miles %
How
many years in Trucking?
Years with your own Insurance?
List
the current auto liability insurance company (if
applicable)
List auto liability insurance company for previous
year (if applicable)
Loss
Information for the Last Three Years
If you have over
2 power units, Insurance Markets
will require Loss Information before they will give
firm proposals. Please fax your loss
runs! Our fax number is 334-566-7215.
If you do not have them or need help getting them,
give Amy Barefoot a call in our office at
334-566-7665.
DRIVERS:
Name
DL#
State
Age
Years Exp Hired mm/yr
Name
DL#
State
Age
Years Exp Hired mm/yr
Name
DL#
State
Age
Years Exp Hired mm/yr
Name
DL#
State
Age
Years Exp Hired mm/yr
Name
DL#
State
Age
Years Exp Hired mm/yr
Name
DL#
State
Age
Years Exp Hired mm/yr
EQUIPMENT:
List
All Trucks, Tractors and Trailers
Year Make Model
VIN Value
Year Make Model
VIN Value
Year Make Model
VIN Value
Year Make Model
VIN Value
Year Make Model
VIN Value
Year Make Model
VIN Value
If
you have more equipment than this form allows, call
our office at 888-385-0186 for a proposal.