Toll Free: (888) 679-8181
Phone: (407) 679-8181
Fax: (407) 679-9300
1) *Your name
2) Name of your trucking company
3) *Mailing Address (PO Box or street, city, zip)
4) *Physical Location (street - no PO Box - city, zip
5) The employer's federal tax ID number for your trucking company
6) *Home or office telephone
7) *Cell phone
8) Fax number
9) *Email address
10) Your motor carrier (MC) number
11) Your DOT number
12) *Please list the states or area of the country in which you operate MOST frequently. For example, Florida to Texas or FL, GA, SC, NC, and AL or Florida only.
*13) Do you have IFTA quarterly fuel tax reports in your name for the last four quarters? Yes No
14) *Type of cargo usually hauled and percentage of time hauled? Please be as specific as possible and avoid terms like "general commodities" or "miscellaneous freight." An example of a correct response is 50% fruit and produce, 10% shrimp and other shellfish, 35% canned and dry grocery products, 5% paper products = 100%.
15) *How did you hear about Hadley & Lyden, Inc.? (friend, magazine advertisement, internet search, or received a letter from Hadley & Lyden)
*16) What is the principal reason that you contacted us for insurance? Poor service from current agent or insurance company Price Interest free payment plan
17) If you want a quote for vehicle liability insurance, please answer the following questions, otherwise go to question 18.
Name of your current vehicle liability insurance company (not agent)
Policy number
Effective (starting) date of policy
Expiration (ending) date of policy
Any vehicle liability accident or claims in the last three years? Yes No
Amount of vehicle liability insurance for which you want a quotation $1,000,000 $750,000 $300,000 other amount
18) If you want a quote for motor truck cargo insurance, please answer the following questions, otherwise go to question 19.
Name of your current motor truck cargo insurance company (not agent)
Any motor truck cargo claims in the last three years? Yes No
Amount of cargo liability insurance for which you want a quotation $50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 other amount
19) If you want a quote for physical damage insurance, please answer the following questions, otherwise go to question 20.
Name of your current physical damage insurance company (not agent)
Any physical damage claims in the last three years? Yes No
20) Provide a description of each tractor, trailer and truck for which you require insurance. Provide the current value of each vehicle for which you want physical damage insurance:
First
Year
Make
Type (tractor, truck, refrigerated trailer, flatbed trailer, dry van trailer, dump trailer, lowboy trailer, car hauler trailer)
VIN (17 characters)
Current Value
Add another tractor, trailer or truck? Yes No
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Nineth
Tenth
21) Driver information is required for all drivers of above vehicles and for corporate officers (even if they do not drive commercial vehicles):
Name of driver
Driver license number
State that issued the driver license
Date of birth
Social Security Number
Date of hire
Add Another Driver? Yes No
* Required
