TOWING INSURANCE QUOTE SHEET

AGENCY HOME PHONE # WORK PHONE# EXT # FAX#

SSN# DOB CURRENT COMPANY

INSURED

LOCATION TERRITORY

NATURE OF BUSINESS

YEAR BUSINEES STARTED

COMMODITY HAULED

MAJOR CITIES ENTERED
DOES APPLICANT:
HAUL FOR HIRE? YES NO HAUL OWN LOADS? YES NO HAUL FOR ONE CONCERN? YES NO
NEED STATE OR FMC FILINGS? YES NO CARRY WORK COMP? YES NO OWN OR USE OTHER UNITS? YES NO
ENGAGE IN PULIC LIVERY? YES NO USE OWNER OPERATIONS? YES NO  
DRIVER INFORMATION:
NUMBER OF EMPLOYEES
VEHICLE INFORMATION

NUMBER OF TRUCKS

LOSS HISTORY
PRIOR CARRIER LIMITS PREMIUM

DESCRIPTION OF LOSSES PRIOR 3 YEARS
PRIOR CANCELLATION OR NONRENEWAL? YES NO

IF YES, PLEASE EXPLAIN
COVERAGES AND LIMITS
LIABILITY UM MEDICAL PAYMENTS

COMPREHENSIVE DEDUCTIBLE COLLISION DEDUCTIBLE ON HOOK

ADDITIONAL COVERAGES