Patriot Agencies

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Commercial Truckers Quote

PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR COMMERCIAL TRUCKERS INSURANCE NEEDS:

NORTH CAROLINA RESIDENTS ONLY.

* = Mandatory

Name: *

Leave Blank:

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Organization:

Home Phone: *

Work Phone:

Fax:

Email: *

Claims Information: Please Show Policy Periods For Last Three Years

From:

To:

Number of Accidents:

From:

To:

Number of Accidents:

From:

To:

Number of Accidents:

Liability - Total Amount of Claims Paid: Bodily Injury:

Property Damage Paid:

Pysical Damage - Total of Claims Paid:

Fire and Theft Claims:

Schedule of Equipment and Rating Information

Vehicle - Unit # 1

Item or Unit #: *

Year Model: *

Trade Name and Kind of Vehicle: *

Terminal Location: *

Capacity, Tons, Gallons, Passenger:

Radius Max Miles:

Date Purchased:

If Used, Purchase Price:

Desired Amount of Insurance: *

Deductible All Perils: *

Desired Effective of Policy or Renewal Date: *

Vehicle - Unit # 2

Item or Unit #:

Year Model:

Trade Name and Kind of Vehicle:

Terminal Location:

Capacity, Tons, Gallons, Passenger:

Radius Max Miles:

Date Purchased:

If Used, Purchase Price:

Desired Amount of Insurance:

Deductible All Perils:

Desired Effective of Policy or Renewal Date:

Vehicle - Unit # 3

Item or Unit #:

Year Model:

Trade Name and Kind of Vehicle:

Terminal Location:

Capacity, Tons, Gallons, Passenger:

Radius Max Miles:

Date Purchased:

If Used, Purchase Price:

Desired Amount of Insurance:

Deductible All Perils:

Desired Effective of Policy or Renewal Date:

Vehicle - Unit # 4

Item or Unit #:

Year Model:

Trade Name and Kind of Vehicle:

Terminal Location:

Capacity, Tons, Gallons, Passenger:

Radius Max Miles:

Date Purchased:

If Used, Purchase Price:

Desired Amount of Insurance:

Deductible All Perils:

Desired Effective of Policy or Renewal Date:

Driver #1

Name: *

License and State: *

Sex: * Male
Female

Date of Birth: *

Tickets In The Last 5 Years: *

Accidents In The Last 3 Years AT FAULT (Date, $, Amount, Personal Injury): *

Accidents In The Last 3 Years NOT AT FAULT (Date): *

Number of Years Licensed: *

Driver #2

Name:

License and State:

Sex: Male
Female

Date of Birth:

Tickets In The Last 5 Years:

Accidents In The Last 3 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 3 Years NOT AT FAULT (Date):

Number of Years Licensed:

Driver #3

Name:

License and State:

Sex: Male
Female

Date of Birth:

Tickets In The Last 5 Years:

Accidents In The Last 3 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 3 Years NOT AT FAULT (Date):

Number of Years Licensed:

Driver #4

Name:

License and State:

Sex: Male
Female

Date of Birth:

Tickets In The Last 5 Years:

Accidents In The Last 3 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 3 Years NOT AT FAULT (Date):

Number of Years Licensed:

Please Select The Limits of Uninsured/Underinsured Coverage Required

Uninsured Motorist Bodily Injury: * $25,000/50,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/1,000,000

Please Select The Limits of Uninsured Property Damage Required

Uninsured Motorist Property Damage: * $15,000
$25,000
$50,000
$100,000

How would you like to receive your quote:

Commercial Truckers Quote

Claims Information: Please Show Policy Periods For Last Three Years

Schedule of Equipment and Rating Information

Vehicle - Unit # 1

Vehicle - Unit # 2

Vehicle - Unit # 3

Vehicle - Unit # 4

Driver #1

Driver #2

Driver #3

Driver #4

Please Select The Limits of Liability Coverage Required

Please Select The Limits of Property Damage Limits Required

Please Select The Limits of Uninsured/Underinsured Coverage Required

Please Select The Limits of Uninsured Property Damage Required