trs quote form

Agency Code*

Producer Name*

Trucking Company

Owner First Name*

Owner Last Name*

Email* Must Enter In AC Contact Record First

Proposed Effective Date*

FEI#

Owner's SS#

Major Cities Driving

Target Premium

Years in Business

If Less Than 3 Years, Provide Employment History For Owner and Drivers

Does Insured Name Match Legal Name in SAFER?

Does DOT # Match SAFER?

Power Units and Drivers

# of Power Units Shown in SAFER

# of Power Units Indicated By Applicant

Explain Any Discrepancy Between Two Figures

# of Drivers Shown in SAFER

# of Drivers Indicated By Applicant

Explain Any Discrepancy Between Two Figures

Does the # of Drivers Match or Exceed # of Power Units? (Check if Yes)

If No, Explain

Radius (Enter Percentage, Must Total 100%)

0-100 Miles

101-300 Miles

301-500 Miles

501+ Miles

Current Carrier Information

Current Carrier Name*

Current Carrier Year*

Current Carrier Effective Date*

# of Years with Current Carrier*

Has This Risk Been Cancelled? (Check if Yes)

Explain Cancellation

Does Insurance Company Name Match SAFER L&I?

Losses

Any Losses in Past 3 Years? (check if yes and complete below)

Loss #1 Date

Loss #1 Amount

Loss #1 Carrier

Loss #1 Driver Involved

Loss #1 Details

Loss #2 Date

Loss #2 Amount

Loss #2 Carrier

Loss #2 Driver Involved

Loss #2 Details

Loss #3 Date

Loss #3 Amount

Loss #3 Carrier

Loss #3 Driver Involved

Loss #3 Details

Loss Runs For 3 Years Are Required. Fax to 239-997-1055 or Email to trs@ibci.net.

Driver Information

Driver #1

Name*

DOB

DL#*

State*

Date Hired*

# of Yrs CDL*

# of Violations*

# of Accidents*

Driver #2

Name

DOB

DL#

State

Date Hired

# of Yrs CDL

# of Violations

# of Accidents

Driver #3

Name

DOB

DL#

State

Date Hired

# of Yrs CDL

# of Violations

# of Accidents

Driver #4

Name

DOB

DL#

State

Date Hired

# of Yrs CDL

# of Violations

# of Accidents

Are ALL Active Drivers Listed? (Check if Yes)

If the Named Insured is a Sole Proprietor, is the Owner a Driver? (Check if Yes)

If No, Provide Owner DL# and DOB

More Than 4 Drivers? Download and Complete The Additional Drivers and Vehicles Supplement to the Right. Fax to 239-997-1055 or Email to trs@ibci.net

Operations

Van

Reefer

Flatbed

Autohauler

Straight U

Source of Load

Source- Direct From Shipper %

Source- Broker %

Main Source #1

Main Source #2

Vehicle Information

Vehicle #1

Year*

Make*

Model/VIN*

# Axles*

GVR*

Stated Value*

Annual Miles*

Vehicle #2 Information

Year

Make

Model/VIN

# Axles

GVR

Stated Value

Annual Miles

Vehicle #3 Information

Year

Make

Model/VIN

# Axles

GVR

Stated Value

Annual Miles

Vehicle #4 Information

Year

Make

Vehicle #4 Model/VIN

Vehicle #4 Axles

Vehicle #4 GVR

Vehicle #4 Stated Value

Vehicle #4 Annual Miles

Is There a Trailer Shown for Every Tractor? (Check if Yes)

Is There a Stated Amount Given For Each Power Unit? (Check if Yes)

Are ALL Power Units and Trailers Listed? (Check if Yes)

If No, Explain.

More Than 4 Vehicles? Download and Complete The Additional Drivers and Vehicles Supplement to the Right. Fax to 239-997-1055 or Email to trs@ibci.net

More Than 5 Power Units? If Yes, Provide IFTA Reports For Past 4 Quarters.

Coverages To Be Quoted- Check All That Apply

Auto Liability

Physical Damage

Cargo

General Liability

Non-Trucking Liability

Physical Damage

Specified Perils

Specified Perils Deductible

Comprehensive

Comprehensive Deductible

Collision

Collision Deductible

Coverage Limits

Auto Liability Limits

UM

UIM

PIP Coverage

Medical Payments

Hired Car

Non-Owned

Other

General Liability

GL Limit

Maximum Cargo Limit

Cargo Deductible

Is There a Limit Shown For Each Coverage Requested?

Are ALL State Required Liability Coverages Shown With a Limit? (Check if Yes)

If No, Explain.

Commodity Transport

Commodity Transport #1*

% of Total #1*

Avg. Value Per Truckload #1*

Max. Value #1*

Commodity Transport #2

% of Total #2

Avg. Value Per Truckload #2

Max. Value #2

Commodity Transport #3

% of Total #3

Avg. Value Per Truckload #3

Max. Value #3

Is a Limit and Deductible Shown For Cargo?

Are Cargo Commodities Shown?

Is Commodity Description Specific?

Are Percentages Hauled, Average and Maximum Values Shown?

Is Maximum Value For Any Commodity Higher Than Cargo Limit Requested?

Explain High Commodity Limits

Quote Comments

Is This Submission 100% Complete and Ready To Quote?