Truck and Trucking Quote - Insurance Service Center

Name*

First Last

Email*

Business Name

Address

Street Address City Kentucky or Tennessee only ZIP Code

We only insure Kentucky and Tennessee

Phone

Fax

Fed Tax ID#

Owner/President

Safety Manager

Number of Full Time Employees

Number of Part Time Employees

Estimated Monthly Payroll

Number of Locations

Years in Business

FHWA Docket Number

US DOT Number

Brokerage Name

Docket Number

Brokerage/FF Revenue (this year)

Estimate for Next Year

Current DOT Rating & Date

Major Metro Areas

Major Shippers

% of Operations 0-75 Miles

% of Operations 76-100 Miles

% of Operations 101-300 Miles

% of Operations 301-500 Miles

% of Operations 501-1000 Miles

% of Regular Routes

Number of Differnt Commodities Hauled

Commodity	Percent Hauled	Average Value	Maximum Value

Last Year Revenue/Mileage History

Estimated Mileage

Estimated Revenue

Number of Units

This Year Revenue/Mileage Estimates

Estimated Mileage

Estimated Revenue

Number of Units

Next Year Revenue/Mileage Estimates

Estimated Mileage

Estimated Revenue

Number of Units

Number of Owned Tractors

Number of Owned Trailers

Owned Service Units

Number of O/O Tractors

Number of O/O Trailers

O/O Service Units

PIP/Medical

Liability Limits

UM/UIM

PIP/Medical

General Liability

Cargo Limit

Comp. Deductible

Collision Deductible

Tractor Values

Trailer Values

Hired Auto Required?

Has your insurance been cancelled or non-renewed in the past 5 years

Agent Name (Optional)

How Did You Hear About Us?

Preferred Contact Method

Additional Comments

Truck and Trucking Quote Request

Last Year Revenue/Mileage History

This Year Revenue/Mileage Estimates

Next Year Revenue/Mileage Estimates

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Personal Lines

Business

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