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Truck Insurance Quote Application

Commercial Carriers Insurance Agency, Inc. Truck Insurance Quote

Insurance Coverages: Workers Compensation • Physical Damage • Liability
Cargo • Trailer Interchange • Excess Liability Warehouse • Medical
Bonds • Hired Auto • Umbrella • Plus many other specialty coverages

DIRECTIONS: To receive a quote for your current truck insurance needs, simply complete the application and push "SUBMIT" - one of our account executives will contact you shortly. If for any reason you feel uncomfortable using our online application, contact us toll-free at (800) 229-8782 or use my direct line (562) 733-6526. Nathan Wallace, Marketing Supervisor.

We currently offer coverage in the following states:

FLEET SUBMISSIONS of 5 or more trucks, click here.

GENERAL INFORMATION
Email (Double check before submitting)
Please list any special notes you would like us to know about, such as issues with your current protection/service or special business operations.
How did you hear about us?	Web address from a: Letter Mailer Friend Magazine MSN Google Yahoo Other
Company name
Owner's name
Your name (If other than owner)	Same as owner
Phone Number:
Do you need an ICC filing?	Yes No
Radius:
Principal Commodity Hauled:	If Other, list:

BUSINESS INFORMATION
years In Business: (with your own truck insurance)
years Driving Experience:
Number of Drivers
Garaging Address:
City
State
Limit of Liability
Do You Need Cargo Coverage?	Yes No
Policy Expiration Date:
Reason you are shopping this year:

EQUIPMENT LIST (List tractors and trailers)
Year	Make	Vehicle Type	Value
If you are a fleet of more than 8 pieces of equipment, how many? Then, SKIP TO NEXT SECTION.

LOSS HISTORY INFORMATION
Number of losses paid by your insurance company (Last 3 years):	Comments:
Number of Tickets (Last 3 years):	Comments:
Internal Use Only

Quote subject to change based upon verification of supplied information.