DUMP TRUCK INSURANCE QUOTE REQUEST
IS GARAGING ADDRESS AND MAILING ADDRESS THE SAME? IF NO, PLEASE COMPLETE THE GARAGING ADDRESS BELOW:
IS THIS A NEW VENTURE? YEARS IN BUSINESS: ANNUAL GROSS RECEIPTS/SALES$
ENTITY TYPE: (IF OTHER, EXPLAIN IN REMARK SECTION)
DESCRIBE BUSINESS OPERATION:
ARE YOU OWNER OPERATOR WITH YOUR OWN AUTHORITY? IF NOT, WHOSE AUTHORITY DO YOU OPERATE UNDER? PLEASE PROVIDE NAME, ADDRESS, PHONE NUMBER AND WEBSITE OF THE AUTHORITY:
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LIST COMMODITIES HAULED AND PERCENTAGE OF LOAD:TOTAL 100% PLEASE BE SPECIFIC. GENERAL FREIGHT MUST BE BROKEN DOWN!
COMMODITY / PACKAGING % OF LOAD COMMODITY / PACKAGING % OF LOAD
MAXIMUM VALUE PER LOAD $ AVERAGE VALUE PER LOAD $
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VEHICLES AND TRAILERS INFORMATION
Year Make Model Tractor
OR
Trailer		 GVW/
GCW		 Vehicle Identification Number Annual
Miles 		Current
Value		 Garaging
Zip Code		 Leased
OR
Owned		 Year Leased
or Purchased
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DRIVERS INFORMATION
Full Name as on Driver’s License Date of Birth Driver License Number License State Years T/T Driving Exp. Marital Status (S) or (M) Numberof Accidents & Tickets 3 Years Date Hired Mo/Yr Owner(O) Or Employee(E)
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SELECT COVERAGE AND LIMITS:
AUTO LIABILTY LIMIT: UNINSURED MOTORIST LIMIT: MEDICAL PAYMENT LIMIT? TRUCK AND OR TRAILER PHYSICAL DAMAGE? IF YES, DEDUCTIBLES:
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DO YOU NEED CARGO COVERAGE? IF YES, COVERAGE LIMIT $ CARGO DEDUCTIBLE
REFRIGRATOR BRAKEDOWN COVERAGE?
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NON-OWNED AUTO LIABILITY? IF YES, # OF EMPLOYEES: HIRED AUTO LIABILITY COVERAGE IF YES, ANNUAL COST OF HIRED AUTO $ GENERAL LIABILITY COVERAGE
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TRAILER INTERCHANGE COVERAGE? IF YES, TRAILER INTERCHANGE MAXIMUM TRAILER VALUE $ # OF TRAILER DAYS PER POWER UNIT: # POWER UNITS UNDER AGREEMENT:
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STATE AND FEDERAL FILINGS:
DO YOU HAVE A US DOT #? IF YES, WHAT IS THE DOT #: IF NOT, DO YOU PLAN TO OBTAIN WITHING THE NEXT 60 DAYS?
DO YOU HAVE A CA MCP#? , IF YES, WHAT IS YOUR CA MCP # IF NOT, DO YOU PLAN TO OBTIAN WITHIN THE NEXT 60 DAYS?
ICC #: MC #: FORM E #: CARGO FILING #: PUC FILING #: SR22 FILING?
INTERMODAL UIIA REQUIREMENTS #: HAVE YOU EVER OPERATED UNDER ANOTHER NAME? IF YES, WHAT WAS THE NAME OF OPERATION: AND THE DOT # AND CA MCP #:
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OPERATIONS (SELECT APPLICABLE):
FOR HIRE PRIVATE NON-TRUCKING FREIGHT BROKER/FORWARDER OTHER

DO YOU HAUL YOUR OWN GOODS EXCLUSIVELY? NON-OWNED GOODS % OWNED GOODS % =100%
LIST PERCENTAGE OF TRIPS IN EACH RADIUS GROUP BELOW – TOTAL MUST BE 100%
0-50 MILES % 51-200 MILES % 201-300 MILES % 300-500 MILES % 500-1500 MILES % 1500M+% =100%
MAJOR CITIES INTO OR THRUOGH WHICH VEHICLE ARE OPERATED: STATES AND COUNTRIES ENTERED: FREQUENCY OF TRIP PER MONTH: FURTHEST ONE WAY DISTANCE IN MILES: WHICH CITY:
DO YOU HAUL DOUBLE AND/OR TRIPLE TRAILERS? IF YES WHICH? DO YOU OWN TRAILERS? ARE YOU THE REGISTERED OWNER OF ALL UNITS LISTED, EXCEPT “UNINDENTIFIED TRAILERS”?
IF NOT, WHO DOES THE TRUCKS/TRAILERS BELONG TO? DO YOU HAUL INTERMODAL/CONTAINERIZED FREIGHT? DO YOU USE SUBHAULERS OR LEASED OPERATORS?
DO YOU RENT OR LEASE VEHICLE TO OTHERS? DO YOU HAUL UNDER LONG TERM CONTRACT? IF YES, PLEASE DESCRIBE CONTRACT AND LENGTH: DO YOU HAUL ANYHAZARDOUS, FLAMMABLE, EXPLOSIVE, CORROSIVE OR CHEMICAL MATERIALS? ARE ALL OWNED TRUCKS AND TRAILERS LISTED ON THIS APPLICATION? FEDERAL TAX ID # FEIN NUMBER IF CORP, LLC, PARTNERSHIP OR OTHER (OPTIONAL): FEDERAL TAX ID SOLE PROPRITORSHIP SOCIAL SECURITY # (OPTIONAL):
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INSURANCE INFORMATION: ARE YOU CURRENTLY INSURED? REQUESTED EFFECTIVE DATE , HAS AN INSURANCE COMPANY CANCELLED OR NON-RENEWED YOUR POLICY IN THE LAST 3 YEARS? HAVE YOU HAD ANY LOSSES OR CLAIMS DURING THE LAST 5 YEARS? IF INSURED NOW, PLEASE PROVIDE INSURANCE POLICY INFORMATION BELOW - LOSS RUNS ARE REQUIRED – PLEASE EMAIL OR FAX THE LOSS RUNS TO OUR OFFICE.
INSURANCE COMPANY(NOT THE AGENCY) POLICY NUMBER EFFECTIVE DATE - EXPIRATION DATE # OF LOSSES (IF ANY) ANNUAL PREMIUM
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STATE THE REASON YOU ARE APPLYING FOR A QUOTE NOW?

This is a request for a price indication. This application does not bind the applicant nor the Company(s) to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

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