Texas trucker insurance


 

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

YearMakeVINGVWACV-Actual CashValue

Largest Cities Entered:

AtlantaBostonBuffaloCharlotte Chicago
Cincinnati ClevelandDallas/Fort WorthDenver Detroit
HartfordHoustonIndianapolisJacksonvilleKansas City
Little RockLos AngelesLouisvilleMemphisMiami
MilwaukeeMinneapolis/St. PaulNashvilleNew Orleans New York City
New Orleans Oklahoma CityOmahaPhiladelphiaPhoenix
PittsburghPortlandRichmondSt. LouisSalt Lake City
San DiegoSan Francisco SeattleTulsa  
Other Cities:123  
Radius TraveledAverage Trip Distance
(Rating Question)		  

Commodities Hauled - Percentages Of Each

1234  
56    

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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