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TransInsurers LLC - Insuring the trucking industry

Trucking Insurance

Group Property & Casualty Insurance Quote Form

Please complete the following form and press submit below.

Tractors, Trailers & Straight Trucks

Type	Year	Make or Brand	Do you need physical damage coverage?	Radius of Operation
1
Enter Stated Value: $			VIN #
2
Enter Stated Value: $			VIN #
3
Enter Stated Value: $			VIN #
4
Enter Stated Value: $			VIN #
5
Enter Stated Value: $			VIN #
6
Enter Stated Value: $			VIN #
7
Enter Stated Value: $			VIN #
8
Enter Stated Value: $			VIN #
9
Enter Stated Value: $			VIN #
10
Enter Stated Value: $			VIN #
	Check here if you have more than 10 Trucks, Tractors, or Straight Trucks; we will contact you for additional information.

Drivers (Including Owner-Operators)

Name of Driver #1	License Number	License State	Years Experience	Date of Birth
1
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
1
Name of Driver #2	License Number	License State	Years Experience	Date of Birth
2
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
2
Name of Driver #3	License Number	License State	Years Experience	Date of Birth
3
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
3
Name of Driver #4	License Number	License State	Years Experience	Date of Birth
4
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
4
Name of Driver #5	License Number	License State	Years Experience	Date of Birth
5
# of Moving Violations	# of Losses or Accidents	Who have you been driving for in the past 3 years?
5
	Check here if you have more than 5 Drivers; we will contact you for additional information.

Please explain any moving violations (date and type) and give dates of any accidents in the box below.

Coverages Required

Bobtail (non trucking liability) Yes No

Occupational Accident Coverage Yes No

Primary Liability Insurance
(maximum 1,000,000) yes no

Limit

Cargo Insurance Yes No

Limit

Deductable

Refrigeration Breakdown Coverage Yes No

Do you need to insure someone
else�s trailer? yes no

Enter Limit

General Liability Insurance yes no

Total Payroll Amount

Total Driver Payroll Amount

Miscellaneous

Current Insurance Company Name

Have you had any losses in
the past three years? Yes No

Why are you shopping for
other coverage?

Please enter any other information you feel may assist us in providing you a quote.

Submit the Form

By submitting a quote request, you acknowledge that credit reports and motor vehicle reports may be reviewed as part of the quote process. To protect your privacy, we will not share the information with anyone except the insurance companies we request to quote your coverage.

You also acknowledge that completion of this form is not to be construed as a solicitation nor does it obligate us to provide a quote.

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