Fillable Non-Fleet Quote Sheet 1 to 4 Power Units (Risk Placement Services, Inc.)

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Non-Fleet Quote Sheet 1 to 4 Power Units (Risk Placement Services, Inc.)

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Non-Fleet Quote Sheet
1 to 4 Power Units
Underwriter:
Date:
Agency Information
Agent Code:
Agent Name:
State:
Person to Contact:
Insured Information
Insured Name:
Owners Name:
Address:
City: State: Zip:
Insured DOT #:
Brokerage (Y/N):
Insured MC#:
Other State Filings (Please provide ID #s if applicable): Years in Business:
States Entered:
Does the Insured do Doubles or Triples (Y/N):
Major Cities Driving Into or Through:
Prior Carrier Info for the past 3 years
Year Company Name and Policy Number
Losses
(Y/N)
Details Driver Involved
If no prior insurance in own name, provide 3 years of driver employment history:
Driver Information
Driver Name
Date of
Birth
License Number State Date Hired
# of Yrs
CDL
Last 3 Years Violations
# of
Accidents
Vehicle Information
Year Make Model GVW
Present
Value
Radius Miles Comments
Coverage & Limits:
Liability Physical Damage Deductible
Primary Specified Perils
Non-Trucking Comprehensive
Collision
Auto Liability Limits
Cargo Maximum Cargo Limit:
UM
Cargo Deductible:
UIM
PIP Coverage Commodity Transport % of Total Value Per Truckload
Medical Payments
Hired Car
Non-Owned
GL Coverage
Other
What kind of growth and/or changes expected in the next 12 months?
Comments:
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Non-Fleet Quote Sheet 1 to 4 Power Units (Risk Placement Services, Inc.)

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Completed 23 November 2020

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