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Trucking Questionnaire- Website

1. Contact Info

First Name *This question is required.

Last Name *This question is required.

Title

Company Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Country

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Fax Number

Mobile Phone

URL

2. What is the best way to communicate with you? *This question is required.

3. How did you hear about our agency? *This question is required.

4. Current Insurance

Current Company
Current Agency
How Long with Agency
Current Expiration Date
Current Monthly Premium

5. Company Info *This question is required.

Year Business Started
Number of Trucks
Number of Employee's

6. Insurance Requested *This question is required.

7. Filings
Check necessary filings:

Check Necessary fillings

Federal
State

Filing Numbers

DOT #
MC #

Any other filings required (i.e. OS-32)?

List Other Filings requested

8. Cargo Transported: List the types of cargo transported
*This question is required.

1
2
3
4
5
6

9. Radius of Vehicles *This question is required.

Space Cell	Number of Vehicles
0-100 Miles	0-100 Miles: Number of Vehicles
101-200 Miles	101-200 Miles: Number of Vehicles
201-300 Miles	201-300 Miles: Number of Vehicles
301-500 Miles	301-500 Miles: Number of Vehicles
Over 500 Miles	Over 500 Miles: Number of Vehicles

Check the States a Filing is Required *This question is required.

West Virginia
Wisconsin
Wyoming

10. Check the States witch the insured travels *This question is required.

West Virginia
Wisconsin
Wyoming

11. General Information *This question is required.

12. Explain any YES answers to questions above and reference the number.

Space Cell	YES	NO
Do you haul for others?	Do you haul for others?: YES	Do you haul for others?: NO
Do you haul for yourselves?	Do you haul for yourselves?: YES	Do you haul for yourselves?: NO
Do you operate under the permits of others?	Do you operate under the permits of others? : YES	Do you operate under the permits of others? : NO
Do you have vehicles registered or garaged in another state?	Do you have vehicles registered or garaged in another state?: YES	Do you have vehicles registered or garaged in another state?: NO
Do you act as a freight forwarder or broker?	Do you act as a freight forwarder or broker?: YES	Do you act as a freight forwarder or broker?: NO
Do you lease or hire vehicles/trailers from others?	Do you lease or hire vehicles/trailers from others?: YES	Do you lease or hire vehicles/trailers from others?: NO
Do you transport Hazardous Materials?	Do you transport Hazardous Materials?: YES	Do you transport Hazardous Materials?: NO
Do you pull double or triple trailers?	Do you pull double or triple trailers?: YES	Do you pull double or triple trailers?: NO
Do you haul any over-sized loads?	Do you haul any over-sized loads?: YES	Do you haul any over-sized loads?: NO
Do you do any trip leasing?	Do you do any trip leasing?: YES	Do you do any trip leasing?: NO
Do you do any trailer interchange?	Do you do any trailer interchange?: YES	Do you do any trailer interchange?: NO
Do you do any inter modal transportation?	Do you do any inter modal transportation?: YES	Do you do any inter modal transportation?: NO
Do do you do any work with hydraulic fracturing (Hydro-fracking)?	Do do you do any work with hydraulic fracturing (Hydro-fracking)?: YES	Do do you do any work with hydraulic fracturing (Hydro-fracking)?: NO
Are you involved in any other operations? (i.e. warehousing, landfill, towing, etc)	Are you involved in any other operations? (i.e. warehousing, landfill, towing, etc): YES	Are you involved in any other operations? (i.e. warehousing, landfill, towing, etc): NO