AJS INSURANCE

TRUCKING QUOTE

Fill out this Truck Insurance Quote form to obtain a Primary Liability/Physical Damage/Motor Truck Cargo Quote. One of our representatives will contact you shortly with a price quote. All information will be kept confidential and is never sold or distributed.

Your Name (First & Last Name): Phone Number: Mailing Address: City: State: Zip Code: Email Address:
Do you have your own authority (ICC/ Motor Carrier Authority)? Yes No
If Yes: What is your ICC or MC number? What type of cargo do you haul? If Other: Please specify here: What is the radius of your operation (in miles)?
Please provide the following information for all owned power units and trailers:
Year	Make/Model	GVW	Value
1.
2.
3.
4.

Please provide the following information for all drivers:

Age	Years of CDL Experience
Driver 1.
Driver 2.
Driver 3.
Driver 4.

Any moving violations in the past three years? Yes No

Any Accidents in the past 3 years (regardless of fault)? Yes No

How much liability coverage do you require?

Primary Liability Non-Trucking Liability (Bob Tail)

How much cargo coverage do you require?

Is refrigeration breakdown coverage required? Yes No