Call: 909.581.7218
License # 0A91014
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Truck, Trucking & Truckers Insurance Quote
Contact Name:
Business Name:
Street Address:
City, State & Zip:
E-Mail Address:
Telephone:
Fax:
Garage Address:
Owner/President:
Safety Manager:
Years in Business:
Other Manager:
Policy Information
Limits of Liability:
Inception Date:
Primary:
Deductibles:
UM / UIM:
Comp:
PIP / Medical:
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Coll:
GL:
Yes
No
Physical Damage:
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Tractor Values:
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Trailer Values:
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Yes
No
Policy Cancellation/Non-renewal last 5 years:
No
Yes
Operations
FHWA Docket #:
USDOT #:
Brokerage Name:
Docket #:
Brokerage/FF Revenue (this year):
Estimate for Next Year ($):
Current DOT Rating & Date:
Percentage of Radius of Operations
0-75:
301-500:
76-100:
500-1000:
Unlm:
Regular Routes:
Major Metro Areas:
Major Shippers:
Commodities Hauled
Commodity
% Hauled
Average Value
Maximum Value
Revenue/Mileage History
Yearly Estimates
Mileage
Revenue
# Units
For Year b/f last:
For Last Year:
For Coming Year:
Equipment
# Tractors
# of Trailers
# of Service Units
Owned:
O / O:
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Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
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Alan Winston
John Place
Jerry Bator
Lewann Hepfler
Leticia Martinez
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Winston & Associates Insurance
8570 Utica Ave., Suite 200, Rancho Cucamonga, California 91730
Tel: 909.581.7218 | Fax: 909.581.7228 |
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