Trucking Quote Sheet
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1ECK AGENCY, INC - ATTICA, KS
Need By Date__________
TRUCKING QUOTE SHEET
Target Prem $__________
Agent____________________
CONTACT INFORMATION
Referred by_______________
Insured ______________________________________________ dba________________________________
TRUCKING CHECKLIST
(**Name & Address must match trucking authority filed with KCC or FMCSA)
**Must do before quoting Trucking**
Mailing Address__________________________ City__________________ St__________ Zip__________
___ Check FMCSA
BMC91X Liab Filing needed for Interstate
Contact Name_____________________________ Email_________________________________________
___ Check KCC
Form E & H needed for Intrastate
Cell Phone______________________ Work_______________________ Home_______________________
___ Check Filing/Policy Renewal Date
35-day wait to cancel filings unless at renewal
Fax___________________ FEIN___________________ Yr Bus Began____________
___ 3-Yr Loss Runs from prior carrier(s)
Required by UW before they will quote
*If quoting Progressive will need owner SSN____________________ & Permission to run credit_________
unless New Venture
___ Last 4 Qtr IFTA Reports
If Interstate they may file & UW needs last 4 qtrs
BUSINESS INFORMATION
Entity Type: Sole Prop______ Partnership______ Corp______ LLC______ # Yrs Experience in Trkg___________ RENEWAL DATE___________
Current Ins_____________________________________________________ Current Premium$________________ Filings Needed?______________
FEDERAL: Liability/91X_____ MCS90 (Pollution)_____
STATE: Liability/Form E_____ Cargo/Form H_____
(**Risk may need MCS90 even if no Federal Filing required if hauling anything with gasoline or passengers as required by DOT)
DOT# ___ ___ ___ ___ ___ ___ ___ Docket# MC___ ___ ___ ___ ___ ___
KCC MCID ___ ___ ___ ___ ___ ___ List States Needed:_____________
Largest cities you enter:___________________________________________________________________________________________________________
Any claims the last 3 yrs? If yes, give details__________________________________________________________________________________________
VEHICLES
*See attached spreadsheets for units____
Are we insuring all owned/operated/leased/rented/borrowed units? ____ (Required with filings)
Any vehicles titled in another name?_______________________________________________
Unit#
Year
Make
Model
VIN
GVW
VALUE
Radius
Cargo (X)
(for PD)
COVERAGES
AUTO LIABILITY LIMIT: $350,000_______
$500,000_______ $750,000_______
$1,000,000_______
(State Filing Minimum)
(Federal Filing Minimum)
UNINSURED/UNDERINSURED LIMIT: $50,000______ $100,000______ $350,000______ $500,000______ $1,000,000______
CARGO LIMIT: $__________________
DEDUCTIBLE: $1,000_______ $2,500_______ $5,000_______
____________________________________________________________________________
List Commodities Hauled
(‘General Freight’ not acceptable)
GENERAL LIABILITY LIMIT: (Optional) $______________ Rejected _____ EXCESS LIABILITY LIMIT: $_______________ Rejected____
GL Rating Base - Driver Payroll $______________
DRIVERS
*See attached spreadsheets for drivers____
Listed Driver
DOB
DL#
State
Marital
Original CDL Yr
Yrs Driving Exp
Date Hired
Status
this type
Non-Trucking Risks:
Coverage(s) desired
Non-Trucking Liability____ Physical Damage ____
Company you are leased on to_________________________________ Address______________________________________________________________
(Will not need Auto Liability due to driving under their authority)
Their DOT#____ ____ ____ ____ ____ ____ ____ Contact Name____________________________________ Phone___________________________
N:/CSR Files/Quote Sheets/Commercial Lines/Trucking Quote Sheet 11/2015
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