Request For Quote

BROKER'S REQUEST FOR QUOTE (1-4 UNITS)
FOR USE BY APPOINTED INTERLINE BROKERS ONLY.

Today's Date

Agency

Producer

PROSPECT INFORMATION:

Insured's Name		DBA:
Coverage Eff Date		Target Price		Yrs In Bus.
CA No.		ICC No.		New Venture?	Yes No
Mailing Adress
City			State	Zip Code
Telephone
Garaging Location: City			State	Zip Code
Any other garaging locations?	Yes No	If yes, please list
Specific commodities hauled (breakdown by %)
Target Commodities
List cities hauled through
Is insured a UIIA hauler?	Yes No	(ANSWER ONLY IF INSURED HAULS CONTAINERS)

COVERAGES:

Liability Limit		Liability Deductible
Uninsured Motorist $30,000/$60,000	Yes No	Phys Damage Deductible
Cargo Limit		Cargo Deductible	Is Refer Breakdown Needed	Yes No
General Liability
Other (please specify)	Work Comp Hired Auto ENO Trailer Interchange Property Equipment Floater Other

DRIVERS:

VEHICLES

If "Truck", give GVW

Are there any other owned vehicles? Yes No

If yes, explain:

PRIOR INSURANCE COMPANY & LOSS HISTORY INFORMATION (must have to quote):

DESCRIBE ANY ACCIDENT WITHIN THE LAST 3 YEARS, REGARDLESS OF FAULT (including accidents that do not show on the MVR(s).)

Which Underwriter would you like to send this information to?

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