One Page Quote Sheet - Sunforest Transportation Insurance
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1Broker:
Email:
One Page Quote Sheet
NAME:
OWNER &
DOB:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
S.S. Number for President
EFFECTIVE:
Quote Needed By:
MC#:
DOT#:
Ever Been Cancelled/Non Renewed?
COMMODITIES:
Any Metals (Copper/Aluminum)?
OS/OW?
RADIUS by %:
UNDER 50
51-300
300-500
Over 500
ANNUAL MILEAGE _________________
Furthest State Traveled:
MAJOR CITIES TRAVELED TO/THROUGH:
YEARS IN BUSINESS:
Team Driving/Passengers?
ANNUAL REVENUE: ________________
LOSS HISTORY:
Ins. Co
Liability
APD
MTC
CURRENT YEAR
YEAR 2
YEAR 3
YEAR 4
DRIVER:
NAME
DOB
DL #/State
Yrs Exp.
Date of Hire
Violations: 3 YEARS
**MVRS ARE REQUIRED BEFORE BINDING COVERAGE.
UNITS:
Year
Make
VIN
GVW
Trl Type
Value
Owned or Owner Oper.
COVERAGES (MARK/COMPLETE APPROPRIATE SELECTIONS)
AUTO LIABILITY
750,000
1,000,000
UM LIMIT
BASIC
MATCHING
NON-TRUCKING – Leased to:
750,000
1,000,000
AUTO PHYSICAL DAMAGE
500
1000
2500
CARGO LIMIT ($10,000-$250,000)
CARGO DEDUCTIBLE
500
1000
2500
GENERAL LIABILITY
750,000
1,000,000
OTHER (Hired Car, Non-owned, Trailer Int., etc.)
IF WE CANNOT PROVIDE PACKAGE QUOTE, WOULD YOU LIKE
YES
MONOLINE APD/MTC?
NO
PROPOSALS OBTAINED THROUGH THE USE OF THIS FORM ARE SUBJECT TO COMPLETED APPLICATIONS, MVR
VERIFICATION, AND FINAL APPROVAL FROM THE INSURING COMPANY. THIS FORM DOES NOT REPLACE THE
INSURING COMPANY’S OWN APPLICATION
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