Trucking Quote - White & Associates Insurance

Name*

Phone Number*

Your Email Address*

Business Name*

Business Address

Street Address Address Line 2 City State ZIP Code

FEIN Tax ID*

Years in business*

Website address*

Policy Effective Date

# of employees

USDOT #*

MC #*

# of Drivers

Type of trucking performed

Hotshot
Bobtail
Short Haul less 300 miles
Long Haul 300 plus miles
Other

Other

Types of trailers

Utility
Reefer
Flatbed
Dry Weight
Gooseneck
Other

Other

Commodities hauled

# of units

Drivers license state

Truck (Make, Model, year)

Date of Birth

Vin #

Radius of travel (ex: 500-1000)

Current Liability limit

Current uninsured motorist/under-insured motorist/ coverage limit

Current comp - collision deductible

Do you have a vehicle maintenance program?

Yes
No

Do you obtain MVR verification for all drivers?

Yes
No

Are any drivers NOT covered by Workers Compensation?

Yes
No

Do you haul any dangerous, caustic, radioactive, or flammable cargo?

Yes
No

Do you haul target commodities like stereos, tv's, pharmaceuticals, etc.?

Yes
No

Do you hire equipment from others?

Yes
No

Do you rent or lease vehicles or equipment to others with/without operators?

Yes
No

Do you haul for other truckers?

Yes
No

Do other truckers operate under the permit of the applicant?

Yes
No

Percentage of number of units operated by others under your permit?

Is coverage required for travel in Canada or Mexico?

Yes
No

Are drivers compensated per trip?

Yes
No

Any hold harmless agreements?

Yes
No

Any vehicles have special equipment mounted or attached?

Yes
No

Do you pull double or triple trailers?

Yes
No

Select one below:

Double
Triple

Do you have a tow truck or perform towing?

Yes
No

List major cities regularly traveled through.

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