Non-Truckers Liability Insurance Quote - Bobtail Insurance Quote
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Texas Non-Truckers Liability

 

Texas Non-Trucking Liability Insurance Quote Request

Please provide the following information:

Insured Information:

Name

Business Name

Type Of Business (Sole Prop/Inc/LLC/Other)

Street Address

City

State/Province

Zip/Postal Code

County

Garaging Address

Garaging - City

Garaging - State/Province

Garaging - Zip/Postal Code

Garaging - County

Work Phone

Home Phone

Tax ID # or Social

FAX

E-mail

Years in Business:
Effective Date:
Business Description:

Schedule of Vehicles/Trailers

Year Make VIN GVW ACV-Actual CashValue

Largest Cities Entered:

Atlanta Boston Buffalo Charlotte Chicago
Cincinnati Cleveland Dallas/Fort Worth Denver Detroit
Hartford Houston Indianapolis Jacksonville Kansas City
Little Rock Los Angeles Louisville Memphis Miami
Milwaukee Minneapolis/St. Paul Nashville New Orleans New York City
New Orleans Oklahoma City Omaha Philadelphia Phoenix
Pittsburgh Portland Richmond St. Louis Salt Lake City
San Diego San Francisco Seattle Tulsa
Other Cities: 1 2 3
Radius Traveled Average Trip Distance
(Rating Question)

Commodities Hauled - Percentages Of Each

1 2 3 4
5 6

Leasing Info

Number of owned units:
Number of leased units:
Is insured hauling for hire? YesNo

Driver Information

Name
DOB
CDL Number & State
Experience
Date of Hire/Lease
MVR Info

Coverages

Non-Truckers Liab: U/M:
PIP: Comp. DED: SCOL DED:
Coll. DED: Med Pay:
Reefer Breakdown:  
GL CSL: Payroll: Non-trucking:
Other:
Leased to:
Address:

3-Year Prior Carrier and Loss History

Carrier
No. of Losses
Total $ Amount
Current Year
1st Prior Year
2nd Prior Year

Has previous coverage been cancelled or denied?YesNo If yes, please explain why:

Comments:

 

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