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Welcome to Johnson Insurance Management. *** See our privacy statement under get a quote**
Commercial Truckers Quote
PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR COMMERCIAL TRUCKERS INSURANCE NEEDS:
NORTH CAROLINA RESIDENTS ONLY.
* = Mandatory
Name: *
Leave Blank:
Address 1: *
Address 2:
City: *
State: *
Select State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code: *
Organization:
Home Phone: *
Work Phone:
Fax:
Email: *
This Application Is For: *
Liability and Physical Damage
Liability Only
Physical Damage Only
Do You Operate As A: *
Individual
Partnership
Corporation
Area Of Operation: *
North Carolina Only
Interstate
Radius Of Operation: *
1 to 50 Miles
50 to 100 Miles
100 to 200 Miles
Up To 250 Miles
Unlimited
States You Operate In: *
If Limited, Explain:
Location Is: *
Inside City Limits
Outside City Limits
Fire District:
NA
Legal Owner of Business: *
Business Is A: *
Taxi
Bus
Trucking Private
Trucking Contract
Trucking For Hire
Other
If Trucking Business, Type of Cargo Hauled:
If Trucking Business, # Roundtrips Per Day:
Approximate Value of Load:
Is Equipment Leased or Rented to Others:
Yes
No
If Yes, Explain:
#'s of Vehicles Leased:
Is Vehicle Used to Haul Explosives:
Yes
No
Is Vehicle Used to Transport Employees:
Yes
No
Total Number of Vehicles Owned and Operated By Applicant:
Number of Taxis:
Number of Buses:
Number of Trucks:
Number of Tractors:
Number of Semitrailers:
Number of Pleasure Cars
(Include Off Road Equipment
:
Do You Have Commercial Liability Insurance In Force:
Yes
No
Who Was Your Carrier Last Year:
Who Was Your Carrier For 2 Years Before:
Have You Ever Had This Type of Coverage Cancelled, Declined or Renewal Refused:
Yes
No
If Yes, Explain:
Filings Required:
Claims Information: Please Show Policy Periods For Last Three Years
From:
To:
Number of Accidents:
From:
To:
Number of Accidents:
From:
To:
Number of Accidents:
Liability - Total Amount of Claims Paid: Bodily Injury:
Property Damage Paid:
Pysical Damage - Total of Claims Paid:
Fire and Theft Claims:
Schedule of Equipment and Rating Information
Vehicle - Unit # 1
Item or Unit #: *
Year Model: *
Trade Name and Kind of Vehicle: *
Terminal Location: *
Capacity, Tons, Gallons, Passenger:
Radius Max Miles:
Date Purchased:
If Used, Purchase Price:
Desired Amount of Insurance: *
Deductible All Perils: *
Desired Effective of Policy or Renewal Date: *
Vehicle - Unit # 2
Item or Unit #:
Year Model:
Trade Name and Kind of Vehicle:
Terminal Location:
Capacity, Tons, Gallons, Passenger:
Radius Max Miles:
Date Purchased:
If Used, Purchase Price:
Desired Amount of Insurance:
Deductible All Perils:
Desired Effective of Policy or Renewal Date:
Vehicle - Unit # 3
Item or Unit #:
Year Model:
Trade Name and Kind of Vehicle:
Terminal Location:
Capacity, Tons, Gallons, Passenger:
Radius Max Miles:
Date Purchased:
If Used, Purchase Price:
Desired Amount of Insurance:
Deductible All Perils:
Desired Effective of Policy or Renewal Date:
Vehicle - Unit # 4
Item or Unit #:
Year Model:
Trade Name and Kind of Vehicle:
Terminal Location:
Capacity, Tons, Gallons, Passenger:
Radius Max Miles:
Date Purchased:
If Used, Purchase Price:
Desired Amount of Insurance:
Deductible All Perils:
Desired Effective of Policy or Renewal Date:
Driver #1
Name: *
License and State: *
Sex: *
Male
Female
Date of Birth: *
Tickets In The Last 5 Years: *
Accidents In The Last 3 Years
AT FAULT
(Date, $, Amount, Personal Injury)
: *
Accidents In The Last 3 Years
NOT AT FAULT
(Date)
: *
Number of Years Licensed: *
Driver #2
Name:
License and State:
Sex:
Male
Female
Date of Birth:
Tickets In The Last 5 Years:
Accidents In The Last 3 Years
AT FAULT
(Date, $, Amount, Personal Injury)
:
Accidents In The Last 3 Years
NOT AT FAULT
(Date)
:
Number of Years Licensed:
Driver #3
Name:
License and State:
Sex:
Male
Female
Date of Birth:
Tickets In The Last 5 Years:
Accidents In The Last 3 Years
AT FAULT
(Date, $, Amount, Personal Injury)
:
Accidents In The Last 3 Years
NOT AT FAULT
(Date)
:
Number of Years Licensed:
Driver #4
Name:
License and State:
Sex:
Male
Female
Date of Birth:
Tickets In The Last 5 Years:
Accidents In The Last 3 Years
AT FAULT
(Date, $, Amount, Personal Injury)
:
Accidents In The Last 3 Years
NOT AT FAULT
(Date)
:
Number of Years Licensed:
Please Select The Limits of Liability Coverage Required
Bodily Injury Limits: *
$25,000/50,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/1,000,000
Or Combined Single Limits: *
$750,000
$1,000,000
$2,000,000
Uninsured/Underinsured Motorist Bodily Injury: *
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/1,000,000
Please Select The Limits of Property Damage Limits Required
Property Damage Limits: *
$15,000
$25,000
$50,000
$100,000
$300,000
$500,000
$1,000,000
$2,000,000
Medical Payments: *
None
$500
$1,000
$2,000
Please Select The Limits of Uninsured/Underinsured Coverage Required
Uninsured Motorist Bodily Injury: *
$25,000/50,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/1,000,000
Please Select The Limits of Uninsured Property Damage Required
Uninsured Motorist Property Damage: *
$15,000
$25,000
$50,000
$100,000
How would you like to receive your quote:
Email
Telephone
Fax
US Mail
