Insurance Quote Request – Shaggy's Consulting

Layout

Business / Organization *

DOT# *

FEIN *

Year Business Started *

Is Owner A Driver?

Years Experience *

Owner Name *

DOB *

Email *

Phone *

License # *

License State *

Mailing Address *

Garage Address the Same as Home Address? *

Current Insurance Company *

Do you drive under a contract with another company? (ie Amazon)? *

Number Of Drivers *

List of Commodities Hauled (Cannot be "General Freight") *

Is This a Renewal? *

More than 5 Drivers? *

Current Drivers

#1 First and Last Name

#2 First and Last Name

#3 First and Last Name

#4 First and Last Name

#5 First and Last Name

#1 Date Of Birth

#2 Date Of Birth

#3 Date Of Birth

#4 Date Of Birth

#5 Date Of Birth

#1 License No & State

#2 License No & State

#3 License No & State

#4 License No & State

#5 License No & State

#1 Date of CDL & Date of Hire

#2 Date of CDL & Date of Hire

#3 Date of CDL & Date of Hire

#4 Date of CDL & Date of Hire

#5 Date of CDL & Date of Hire

More than 5 Trucks & Trailers? *

If more than 5, please upload vehicle spreadsheet below.

Commercial Vehicles

#1 Year

#2 Year

#3 Year

#4 Year

#5 Year

#1 Make/Model

#2 Make/Model

#3 Make/Model

#4 Make/Model

#5 Make/Model

#1 VIN

#2 VIN

#3 VIN

#4 VIN

#5 VIN

#1 Value

#2 Value

#3 Value

#4 Value

#5 Value

Policy Limits

Mile Radius

Cargo Limit

Auto Liability Limit

Deductible

Physical Damage?

Additional Insured