6676 Corporate Center Parkway, Jacksonville, FL 32216
TEL (844) 527-9489 · FAX (904) 262-6054 ·
Agency / Name: / Date:
Producer / Contact: / Policy Effective Date:
INSURED / Individual Corporation Partnership Other
Name: / Phone #: / () - / Fax #: / () -
Mailing Address: / City: / State: / Zip:
Garaging Location(s) if different / Street: / City: / State: / Zip:
Email Address:
OPERATIONS / For Hire Private Non-Trucking
1. / Number of years primary liability coverage under above Name:
2. / MC#: / US DOT#: / Are filing required? Yes No
3. / Do you lease to others? Yes No If Yes, who must provide primary insurance? You Other
DESCRIPTION OF OPERATIONS
Radius of Operations: / 0100 miles / % / 101300 miles / % / 301500 miles / % / 500 + miles / %
Please list the three largest cities entered in your operation:
COMMODITIES TRANSPORTED Please be specific in listing commodities.
Commodity / % of Loads / Avg. Value / Max. Value / Commodity / % of Loads / Avg. Value / Max. Value$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
SCHEDULE OF AUTOS TO BE INSURED (All units you own or are leased to you must be scheduled and insured if filings are to be made.)
No / Year / Make / Model or Trailer Type / GVW / GCW / Stated Value / Max Radius
1. / $
2. / $
3. / $
DRIVER INFORMATION
No. / Driver / D/O/B / License No. / Full Time Drvr / Owner /Op / ST / # Yrs.
Drv
Similar Equip. / Date
of
Hire / Number Violations
Prior 3 Years / Losses
Prior 3 Years
#
Major / #
Minor / Non
Moving / # of
Acc / Loss Amount
1. / $
2. / $
3. / $
COVERAGE
Auto Liability / $ / CSL
Primary Auto Liability / Uninsured Motorist / $ / Liability
Liability for Non -Truck Use (Bobtail Liability) / Uninsured Motorist PD / $ / PD Limit
Leased to: / Underinsured Motorist / $ / Limit
General Liability / Underinsured Motorist PD / $ / PD Limit
Medical Payments / $ / Limit
Personal Injury Protection / $ / Limit
Physical Damage
Comprehensive & Collision
Specified Perils & Collision / Deductibles
$
$ / Cargo
Limit $
Deductible $ / Deluxe Coverage
Family Emergency Travel Coverage
LOSS HISTORY Must show Current Year LOSS RUNS ARE ATTACHED (If loss runs are attached, please complete unit count for each year)
From / To / Insurance Company / Annual / Unit Count / Amount ($) of Losses
Premium / Liability / Physical Damage / Cargo
$
$
$
Has an insurance company cancelled or non-renewed your policy in the last 3 years? Yes No
NOTE: The Quick Quote Submission form does not replace the Lancer Application which must be completed upon binding. Any misrepresentation or omission of material facts will be cause for account re-rate or possible withdrawal of quote.
Quick Quote Form (01/17) Page 1 of 1