Trucking 1-5 Units Trucking & Transportation 1 to 5 Units Trucking Quote(2) Step 1 of 4 - Applicant Information 0% Are you new to this site?*Please SelectYesNoWe highly recomment registering for this site because it will save you time in the future in receiving quotes and it provides us with security information that we will require in order to assisty you with servicing. Expiration Date of current Insurance MM slash DD slash YYYY Website Email* Enter Email Confirm Email Business Name* Input DBA or if none, type "none" or your Name.Phone Primary*Fax Number:Name* First Last Mailing Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please indicate a mailing address by street or P.O. Box Describe OperationsDescription of Operations / Trucking*Please describe the kind of cargo transportedJust a brief statement or detailed if you wish. Coverage limits requestedLiablity:*Please select$750,000$1,000,000$2,000,000Uninsured Motorists*Please SelectReject$100,000$300,000$1,000,000Medical*Please selectReject$1,000$2,000$5,000Unidentified Trailer limit*Please selectReject$5,000$10,000$20,000$30,000$40,000$50,000$60,000$70,000Cargo Coverage limit: (enter limit desired) Truck / Tractor Units (Up to 5 units on this form)How many Truck / Tractor Units to you have?*1 Trucks / Tractors2 Trucks / Tractors3 Trucks / Tractors4 Trucks / Tractors5 Trucks / TractorsTruck / Tractor Unit 1Truck-Tractor-1 Year, Make & Model* Truck Unit # 1 (GVW or GCW)* Truck-1 Radius* Comp.& Collision on Truck-1?*Please selectRejectYesNoTruck 1 Stated Value # 1 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Truck / Tractor Unit 2Truck-Tractor 2: (Year, Make & Model) Truck Unit # 2 (GVW or GCW) Truck 2 - Radius Comp. & Collision on Truck 2?Please selectYesNoRejectTruck 2 Statef Value Truck 2 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Truck / Tractor Unit 3Truck-Tractor 3: (Year, Make & Model) Truck Unit # 3 (GVW or GCW) Truck 3 - Radius Comp. & Collision on Truck 3?Please selectYesNoRejectTruck 3 Stated Value Truck 3 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Truck / Tractor Unit 4Truck-Tractor 4: (Year, Make & Model) Truck Unit # 4 (GVW or GCW) Truck 4 - Radius Comp.& Collision on Truck 4 ?Please selectYesNoRejectTruck 4 Stated Value Truck 4 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Truck / Tractor Unit 5Truck-Tractort 5: Year, Make & Model Truck Unit # 5 (GVW or GCW) Truck 5 - Radius Comp.& Collision on Truck 5 ?Please selectYesNoRejectTruck 5 Stated Value Truck 5 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Trailer Units (1 to 5)How many Trailer Units do you have?Please selectNoneTrailers 1Trailers 2Trailers 3Trailers 4Trailers 5Trailer 1Trailer Unit 1 Year, Make & Model Trailer 1 Radius Comp.& Collision on Trailer 1?Please selectYesNoRejectTailer 1 State Value Trailer 1 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Trailer 2Trailer Unit 2 Year, Make & Model Trailer 2 Radius Comp.& Collision on Trailer 2?Please selectYesNoRejectTailer 2 State Value Trailer 2 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Trailer 3Trailer Unit 3 Year, Make & Model Trailer 3 Radius Comp.& Collision on Trailer 3?Please selectYesNoRejectTailer 3 State Value Trailer 3 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Trailer 4Trailer Unit 4 Year, Make & Model Trailer 4 Radius Comp.& Collision on Trailer 4?Please selectYesNoRejectTailer 4 State Value Trailer 4 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000Trailer 5Trailer Unit 5 Year, Make & Model Trailer 5 Radius Comp.& Collision on Trailer 5?Please selectYesNoRejectTailer 5 State Value Trailer 5 DeductiblePlease select$500$1,000$2,000$2,500$5,000$10,000 Driver InformaionAll drivers, temporary, seasonal, part-time or full-time must be listed. You can fax the MVR's to 209-223-3227 or Upload them thru this form. You can also have us order them at a cost of $10.00 each. Note: we cannot release the actual mvr to you as a privacy issue. An an alternative you can have your drivers go to DMV and get their own "individual" drivers license.If you have us order the MVR and the data You provided is incorrect you do not get a refund on the order as we do not get a refund. We highly suggest you get clear copies of the MVR's and provide accurate data as to 1.) First and Last name 'as they' appear on the license, Date of Birth, license number and State. If Foreign license number please provide foreign license number. Driver 11. Driver First and Last Name* 1. Date of Birth* 1. License number:* 1. State or Country if International* 1.Years experience driving Class A* 1. How many tickets/accidents 5yrs?* Driver 22. Driver First and Last Name 2. Date of Birth 2. License number: 2. State or Country if International 2.Years experience driving Class A 2. How many tickets/accidents 5yrs? Driver 33. Driver First and Last Name 3. Date of Birth 3. License number: 3. State or Country if International 3.Years experience driving Class A 3. How many tickets/accidents 5yrs? Driver 44. Driver First and Last Name 4. Date of Birth 4. License number: 4. State or Country if International 4.Years experience driving Class A 4. How many tickets/accidents 5yrs? If more drivers or comments enter information here Additional Underwriting InformationDo you use Sub-haulers?* Yes No Sub-hauler Gross Reciepts What kinds of filings do you require?* Department of Motor Vehicle ICC Other Explain "other" Are you "New in this business?"*Please selectYesNoIf new in business then you will not have had prior coverage of your own. If that is the case we need to know who your previous employer(s) were for the last five years.Previous Employer 1 Previous Employer 2 Insurance InformationName of Current Insurance Carrier* If non State "none" Current policy expires on what Date? MM slash DD slash YYYY For how many years have you carried your own insurance?*Please selectOneTwoThreeNew businessPrior Carrier Name 1 Policy Date 1 1. Claim payout $?* Any claims? if non type "none". Prior Carrier Name 2 Policy Date 2 2. Claim payout $? Prior Carrier Name 3 Policy Date 3 3. Claim payout $? You may upload prior loss runs, motor vehicle reports Drop files here or Select files Accepted file types: jpg, git, png, pdf, Max. file size: 64 MB, Max. files: 15. Motor Vehicle Reports Quantity Price: $10.00 Quantity Total Price to be invoiced to you $0.00 An invoice will be prepared and sent via email using Paypal from Athena Insurance and Financial Services
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