Truck Insurance Form Questionnaire

Truck Insurance
Requesting Information Questionnaire

For Informational purposes only
Effective Date:
SSN:
TAX ID:
Business Details:
Business Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Type

Individual Partnership Corporation/LLC
Commodities
Phone Number
E-mail
Radius

0-100 miles 101-300 miles 301-600 miles Over 600 miles
DOT#
MC#

Loss History/Prior Experience

	Company	Policy Period	Loss Amounts, Desc., Dates (attached separate list if needed)
1
2
3
4
5

Owner/Driver Details:

	Driver Name(s)	DOB	DL#	Experience	Date of Hire	Owner/Driver	MVR Record
1
2
3
4
5
6
7
8
9
10

Vehicles:[Truck/Trailers]

	Year	Make and Model	Vehicle Type	VIN#	Value [If Physical damage]
1
2
3
4
5
6
7
8
9
10

Coverage Details:

	Total Amount Outstanding
Liability Limit
Cargo Limit
Cargo Deductible
Phys. Damage Deductible
UM/UIM Limit
Trailer Interchange
Other Coverage

Refrigeration Breakdown

Yes No

Cargo % breakdown of commodities

	Commodities	Max Value/Exposure	% of Time Hauled
1
2
3
4
5
6

COMMENTS
Additional Driver/Vehicle Information
Should be Empty:

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