Commercial Trucking Insurance Quote Request Form

To get a free Commercial Trucking Insurance quote, please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quoting purposes only.

 

General Information
Business Name:
Contact Name:
Mailing Address:
Street Address:
City:        
State:
 Zip:
Business Phone #  
Fax #
Best Time To Call:  AM   PM
Email Address:

 

Current Insurance Information
Insurance Company Name
Policy Expiration Date:

Premium Amount:

Other Providers during the last 3 years?

 

About Your Commercial Trucking Operation
No. Full-Time Employees?
No. Part-Time Employees?
Years Operation In Business?
Total Payroll (For Worker's Compensation)
Gross Receipts (For GL - NTL Quotes)

Please Describe Your Business In Detail

 

Operation Details
Describe Your Hauling Operation, i.e. Cross-Country, 3-State Area, East Coast
Cargo Transported:
Garage Location Town, State and Zip:
Do You Haul Interstate? (Cross State Lines) Yes     No
If Yes, Please List All State Lines Crossed:
Normal Radius:
Maximum Radius:
Annual Mileage:
Driver # 1 Name: Age:
# of Accidents List Accidents
Driver # 2 Name: Age:
# of Accidents List Accidents
Driver # 3 Name: Age:
# of Accidents List Accidents
Driver # 4 Name: Age:
# of Accidents List Accidents
Driver # 5 Name: Age:
# of Accidents List Accidents
Driver # 6 Name: Age:
# of Accidents List Accidents
Driver # 7 Name: Age:
# of Accidents List Accidents
Driver # 8 Name: Age:
# of Accidents List Accidents
Driver # 9 Name: Age:
# of Accidents List Accidents
Driver # 10 Name: Age:
# of Accidents List Accidents
 
Any Claims In Past 3 Years? Please Describe if Yes
Equipment, Trucks and Property To Be Covered, Describe All In Detail (Model, Year, Current Mileage, Condition, Service Records, etc.

 

Additional Information

Please describe any pertinent information that we did not ask on the forms above

 

Permission To Obtain Consumer Reports (Required To Quote)

To provide you with an accurate quote, we have asked you a series of questions, some of which we must confirm through consumer reports. These reports may include credit, motor vehicle and loss information reports from the respective consumer reporting departments/agencies. This information will be available to our companies with whom we will obtain your quote.

Do You Grant Permission to B.I.A., Inc. To Obtain These Reports?

    Yes          No

 

Virginia Fraud Statement

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

I Have Read The Virginia Fraud Statement and Verify that all information is accurate to the Best of my Knowledge and do consent for B.I.A., Inc. to process my Free Quote Request.

I AGREE

I DO NOT AGREE

 

 

C.C. Belcher Insurance Agency

503 Main Street

P.O. Box C (Mail Correspondence)

Haysi, VA 24256

Phone: (276) 865-5144

Trucker's Only: 1-877-411-2421
Fax: (276) 865-5255
Email: matt@belcherinsurance.com

 

Website Content © Copyright 2006 - C. C. Belcher Insurance Agency, Inc.

Insurance Quote Forms © 2006 MainBoard, LLC Web Design - Licensee Belcher Insurance Agency, Inc.

Notice: This website provides a simplified description of coverage only and is not a statement of contract. Coverage may not apply in all states. For complete details of coverage,  conditions, limits and losses not covered, be sure to read the policy, including all endorsements.