Commercial Auto Quick Quote - For 4 or less vehicles only

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Commercial Auto Quick Quote - For 4 or less vehicles only


Agency Information:

* = Required
Agency Name*

Contact Person*

Email*
Phone

Fax


Applicant Information:

Business Name*

Principal Owner*

Mailing Address 1*

Mailing Address 2

City, State Zip*
, County


Phone*


Garage Address 1 if Different from Mailing Address

Garage Address 2

Garage City, State Zip
, Garage County

Federal ID or SSN

Year Business Started*

Date Coverage Desired

Current Premium

U.S. DOT Number*

MC#

Are State filings needed? Yes:  No: 
List State(s) and Auth# (if app)

Does applicant own or operate any equipment over 10,000 GVW not listed in this application?
Yes:  No: 
Does applicant hire any equipment?
Yes:  No: 
What is the annual cost of hire?

Description of Business*


Schedule of Drivers*

Name
Date of Birth
State & License #
3 Yr Acc & Viol History
Yrs Exp*
Date of Hire
*Experience Driving Similar Vehicles

Vehicle Schedule

Year
Trade Name
Type of Vehicle
GVW
Current Value
Maximum Radius

Prior 3 Year Carrier Information

 
Liability Carrier
Phys Dam Carrier
Cargo Carrier
Last Yr
1 Yr Prior
2-Yr-Prior

Loss History

 
# Losses
Loss Amount Paid
Loss Description
Driver Name
Last Yr
1 Yr Prior
2-Yr-Prior

Coverages

Bodily Injury Liability/Property Damage Liability
Hired
N/O
Uninsured Uninsured Motorist Liability
Medical Payments Personal Injury Protection
Comprehensive
Collision
Cargo
General Liability
Other

Limits of Liability

$CSL Primary Non Trucking
$Cost of hire
   # Employees
$CSL
$Each Person
$Deductible
$Deductible
$Limit $Deductible
$General Aggregate $Per Occurrence
   

Prior Employer Info (New Ventures Only)

Driver
Employer
Dates of Employment
Type of Unit
-
-

Radius of Operations

0-50 miles
51-100 miles
101-200 miles
201-300 miles
301-500 miles
501+ miles
Maximum Radius

Five Most Common Hauls By Destination:
1. 2. 3. 4. 5.
Largest Cities Entered (Pick Up or Drop Off)
1. 2. 3. 4. 5.

Cargo Hauled*
%*
Average Value

Main Shipping Customers
Percentage of Loads
Number of Years Hauling For

Percentage of Loads Received Through Freight Brokers:


Operation History

 
Projected
Past Year
Past Year 2
Past Year 3
Revenue
Mileage
Units Operated

Additional Remarks

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Interstate Insurance Management is a series of RSG Underwriting Managers, LLC. RSG Underwriting Managers is a Delaware Series limited
liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Insurance Services, LLC License # 0E50879
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