FREE Quote for your insurance needs.
TRUCK INSURANCE RATE QUOTATION REQUEST
Please fill in this form accurately and completely. Your premium quote will be based on information that you give us. This is a request for a rate quote only, not application for a policy. Rates are subject to change. As always, there is no obligation.

GENERAL INFORMATION
Name
Mailing Address City,ZIP
Garage Address City,ZIP
Insured's Name Commodities
Transported %
Years In Business
Phone Work Radius
Phone Fax E-mail
Limits Liability$ Limits U.M.$ Limits Med.Pay$
Liability Deductible:PD & BI

DRIVER INFORMATION
DRIVER NUMBER 1
Driver Name
M/F
D.O.B.
Drivers Lic.
Years Exp.
Has driver recieved or been involved with tickets/accidents? If yes, how many
DRIVER NUMBER 2
Driver Name
M/F
D.O.B.
Drivers Lic.
Years Exp.
Has driver recieved or been involved with tickets/accidents? If yes, how many
DRIVER NUMBER 3
Driver Name
M/F
D.O.B.
Drivers Lic.
Years Exp.
Has driver recieved or been involved with tickets/accidents? If yes, how many
DRIVER NUMBER 4
Driver Name
M/F
D.O.B.
Drivers Lic.
Years Exp.
Has driver recieved or been involved with tickets/accidents? If yes, how many
POWER UNIT/VEHICLE NUMBER ONE INFORMATION
Year Make Value $ Deductible
Trailer Value $ Deductible

POWER UNIT/VEHICLE NUMBER TWO INFORMATION
Year Make Value $ Deductible
Trailer Value $ Deductible

POWER UNIT/VEHICLE NUMBER THREE INFORMATION
Year Make Value $ Deductible
Trailer Value $ Deductible

POWER UNIT/VEHICLE NUMBER FOUR INFORMATION
Year Make Value $ Deductible
Trailer Value $ Deductible

COVERAGES
Sub-Haulers If yes, indicate annual gross receipts:
Cargo If yes, list Cargo Limit Per Trailer:
Filings Required DMV ICC Form E
Prior Carrier & Loss Information
Loss Ratio (last 3 yrs)
Current Ins Co Current Policy Exp
Current Agent

   
The information contained here is general in nature, and cannot cover all circumstances or policies. For specific information, please refer to the actual policies, or contact us and we'll be happy to help.
You can reach Garcia & Associates Insurance at 1-800-350-9207 or via E-mail at info@garciainsurance.com.

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Copyright 1999 Garcia & Associates Insurance, 418 Oak Street, Bakersfield, CA