Texas Non-Truckers Liability Insurance Quote Form

Or Fill Out Our On-Line Rater:

Insured Information

Name

Business name

Type Of Business (Sole Prop/Inc/LLC/other)

Street Address

City

State/ Province

Zip/Postal Code

County

Garaging Address

Garaging City

Garaging - State/Province

Garaging - Zip/Postal Code

Garaging - County

Work Phone

Home Phone

Tax ID # or Social

FAX

E-mail

Years in Business

Effective Date

Business Description

Schedule of Vehicles/Trailers

Year

Make

VIN

GVW

ACV-Actual CashValue

Average Trip Distance(Rating Question)

Radius Traveled

Commodities Hauled - Percentages Of Each

Leasing Info

Number of owned units

Number of leased units

Is insured hauling for hire?

Yes

Driver Information

Name

DOB

CDL Number & State

Experience

Date of Hire/Lease

MVR Info

Coverages

Bobtail Liab CSL

Excess Liab:

U/M

PIP

Comp. DED

SCOL DED

Coll. DED

Med Pay

Cargo DED

GL CSL

Excess Cargo

Other

Leased to

Address

Non-trucking

3-Year Prior Carrier and Loss History

Carrier

No. of Losses

Total $ Amount

Current year

1st Prior Year

2nd Prior Year

Has previous coverage been cancelled or denied?

Yes

If yes, please explain why:

Comment