Transportation Insurance

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Quote Transportation Insurance

"*" indicates required fields

1INTRO

2Liability Limit

3DRIVER 1-4

4Driver 5-8

5Driver 9-12

We require at least 7 working days lead time and "full and complete" information in order to process your quote request. This form is designed for up to 12 vehicles which include tractors, trucks, trailer, pickups, semi-trailers and Pup trailers.

Need by Date (must have 7 days lead time)*

DD slash MM slash YYYY

TOTAL VEHICLES

How many vehicles in total?*

TOTAL DRIVERS

How many drivers in total?*

CHECK COVERAGE TO QUOTE

Select all that apply*

General Liability

Business Auto

Cargo

Select all that apply

Workers Compensaton

Directors & Officers

Office Policy

INSURANCE HISTORY

Have you or do you have prior insurance with no more than a 30 day lapse in coverage?

Yes

Have you or will you provide your insurance claim history within 6 working days?

Our carriers will not begin working on quotes without prior history "provided you have prior insurance." Some carriers require prior insurance. We write with several carriers. It is required that you order loss runs or provide them in order for us to begin working. If you are a new venture this does not apply to you.

Yes

If you have them now please upload loss runs and prior policy

You may also email loss runs and prior policy to insurance@athenainsurance.com in a separate email. Use a .pdf format. You may also use U.S. postal delivery to 205 Court Street, Jackson CA 95642.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 9.

BUSINESS DESCRIPTION OF OPERATIONS

Legal Business Name*

Doing Business As...

Is there a DBA?

Yes

Entity Type

Contacts Name*

person completing this form

Email*

Enter Email Confirm Email

Phone*

Fax

Physical Locations

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the "Physical location" the same as the mailing address

Yes

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of person to contact for inspection*

Have you ever had insurance with one of the following Insurance Companies?*

Please Check all that apply

None of these listed

National Fire & Marine Insurance Company

National Indemnity Company

National Indemnity Company of Mid America

National Liability & Fire Insurance Company

Dongbu

Progressive Insurance Company

Please provide name of current insurance carrier (if applicable) include expiration date

Please describe your business*

Is this a new venture?

Yes

Years of experience

Is this your primary business?*

Yes

Please describe the other business

Is this a seasonal business?

Yes

Have you ever filed for bankruptcy?

Regarding the bankruptcy... when and explain

Gross receipts for last year?*

"Projected" gross receipts for this next 12 months?*

Is the business for sale?*

Yes

Do you operate in more than one State?*

Yes

List of States in which you operate

Do you haul for hire?*

Yes

List Largest Cities entered*

Do you operate over a regular route?*

Yes

If yes, show town operated between

Are you a common carrier?*

Yes

Are you a contract hauler?*

Yes

If, yes.. for whom?

List all types of cargo hauled*

Do you haul any hazardous or extra hazardous substances or materials as defined by EPA?*

Yes

If yes, please provide complete listing identifying all material(s) and/or chemical content

Do you haul your own cargo exclusively?*

Yes

If not, who owns it?

Do you pull double trailers?*

Yes

Do you pull triple trailers?*

Yes

Do you rent or lease your vehicles to others?*

Yes

If yes, upload or email rental or lease agreement for used

If you prefer you may email to insurance@athenainsurance.com and be sure to include the company name and phone number please.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 3.

Do you hire any vehicles?*

Yes

Please attached a copy of the lease agreement

or email to insurance@athenainsurance.com

Max. file size: 128 MB.

LIABILITY COVERAGE

Complete for desired coverages by indicating limits of insurance.

Combined Single Limit Bodily Injury and Property damage*

Medical Payments*

Personal Injury Protection *(where available)

DRIVER INFORMATION 1-4

1 Name First & Last

2 Name First & Last

3 Name First & Last

4 Name first and last

1 Marital Status*

2 Marital Status

3 Marital Status

4 Marital Status

1 Date of Birth*

2 Date of Birth

3 Date of Birth

4 Date of Birth

1 State Licensed*

2 State Licensed

3 State Licensed

4 State Licensed

1 License Number*

2 License Number

3 License Number

4 License Number

1. Class / Type (ie cdl)*

2 Class / Type (ie cdl)

3 Class / Type (ie cdl)

4 Class / Type (ie cdl)

EXPERIENCE & DATE OF HIRE

1 Years licensed in class*

2 Years licensed in class

3 Years licensed in class

4 Years licensed in class

1 Type of Unit(S) driven (Bus, Van, Truck, Tractor)*

2 Type of Unit(S) driven (Bus, Van, Truck, Tractor)

3 Type of Unit(S) driven (Bus, Van, Truck, Tractor)

4 Type of Unit(S) driven (Bus, Van, Truck, Tractor)

1 Years of Experiences*

Number of years of previous "commercial" driving experience

2 Years of Experience

Number of years of previous "commercial" driving experience

3 Years of Experience

Number of years of previous "commercial" driving experience

4 Years of Experience

Number of years of previous "commercial" driving experience

1 Date of Hire*

DD slash MM slash YYYY

2 Date of Hire

DD slash MM slash YYYY

3 Date of Hire

DD slash MM slash YYYY

4 Date of Hire

DD slash MM slash YYYY

MINORS - Driving Record Minor Violations & Accidents

1 Driving Record Minor Violations & Accidents

Accidents and all moving traffic violations in the Past 5 years. Include date(s) for each violation and accident.

2 Driving Record Minor Violations & Accidents

Accidents and all moving traffic violations in the Past 5 years. Include date(s) for each violation and accident.

3 Driving Record Minor Violations & Accidents

Accidents and all moving traffic violations in the Past 5 years. Include date(s) for each violation and accident.

3 Driving Record Minor Violations & Accidents

Accidents and all moving traffic violations in the Past 5 years. Include date(s) for each violation and accident.

MAJORS - Driving Record cont. Major Violations +

DWI/DUI, Hit & Run, Manslaughter, Reckless Driving, Driving While suspended or revoked, speed contest or other felony. Describe Conviction and date(s) Also, indicate if Employee, Independent Contractor, Owner or Franchise.

1 Majors

Driver 2 Majors

Driver 3 Majors

Driver 4 Majors

Are all drivers covered by Workers Compensation?*

Yes

You answered "yes" to workers compensation. Please provide name of carrier

Minimum years driving experience required*

Are drivers ever allowed to take vehicles home at night?*

Yes

If yes, will family members drive?

Yes

Do you order MVR's on all drivers prior to hiring?*

Yes

Drivers Maximum hours daily?*

Drivers Maximum hours weekluy?*

Do you agree to report all newly hired operators?*

Yes

What is the basis for driver pay?

Hourly

Trip

Mileage

Other

Explain "other"

DRIVER INFORMATION 5-8

5 Name First & Last

First and last name as it appears exactly on the drivers license

6 Name First & Last

First and last name as it appears exactly on the drivers license

7 Name First & Last

First and last name as it appears exactly on the drivers license

8 Name First & Last

First and last name as it appears exactly on the drivers license

5 Marital Status

6 Marital Status

7 Marital Status

8 Marital Status

5 Date of Birth

6 Date of Birth

7 Date of Birth

8 Date of Birth

5 State Licensed

DRIVER INFORMATION 9-12

9 Name First & last

9 Marital Status

9 Date of Birth

9 State Licensed

SCHEDULE OF AUTOS/VEHICLES

Describe all vehicles for which application is made for insurance

1 Year Manufactured

2 Year Manufactured

3 Year Manufactured

4 Year Manufactured

1 Make & Model

2 Make & Model

3 Make & Model

4 Make & Model

1 Body Type*

Truck, Tractor, Trailer, etc.

2 Body Type

Truck, Tractor, Trailer, etc

3 Body Type

Truck, Tractor, Trailer, etc

4 Body Type

Truck, Tractor, Trailer, etc

1. Vehicle Identification Number

2. Vehicle Identification Number

3. Vehicle Identification Number

4. Vehicle Identification Number

1 Gross Vehicle Weight

2 Gross Vehicle Weight

3 Gross Vehicle Weight

4 Gross Vehicle Weight

1 Total number of rear axles

2 Total number of rear axles

3 Total number of rear axles

4 Total number of rear axles

1 Principal Garaging Location

City and State

2 Principal Garaging Location

City and State

3 Principal Garaging Location

City and State

4 Principal Garaging Location

City and State

1 Radius of operation

2 Radius of operations

3 Radius of operations

4 Radius of operations

1 Annual mileage*

2 Annual mileage

3 Annual mileage

4 Annual mileage

1 Anti-lock brakes*

Yes

2 Anti-lock brakes

Yes

3 Anti-lock brakes

Yes

4 Anti-lock brakes

Yes

1 Air Bags

Yes

2 Air Bags

Yes

3 Air Bags

Yes

4 Air Bags

Yes

Is vehicle 1 leased?

Yes

Is vehicle 2 leased?

Yes

Is vehicle 3 leased?

Yes

Is vehicle 4 leased?

Yes

Vehicle 1 lessors Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vehicle 2 lessors Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vehicle 3 lessors Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vehicle 4 lessors Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PHYSICAL DAMAGE COVERAGE VEH. 1-4

Complete spaces below for each vehicle listed 1-4

Untitled