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Truckers Quote Form

Please fill out this quote form to the best of your knowledge, and we will contact your for more information if needed.

By providing my phone number to “Mass Trans Insurance Agency Inc”, I agree and acknowledge that “Mass Trans Insurance Agency Inc” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

*Corporate or Individual Name (Include DBA): FEIN/ Tax ID
Physical Address:
*Contact: *Phone: Email:
Need Federal Filing / BOC-3? Yes No DOT#: MC#:
Fully describe your operation include the products and commodities hauled:
Current Insurance? Yes NoDate coverage is being requested:
Ins. Company: Expiration Date: Type of Ins.:
Ins. Company: Expiration Date: Type of Ins.:

Coverage & Limits Requested – All Quotations will be for Specified Autos only – Check all that apply

AUTO LIABILITY
$60,000 CSL$25/$50/$10
$100,000 CSL$50/$100/$25
$300,000 CSL$100/$300/$50
$500,000 CSL$250/$50/$100
$750,000 CSLOther
$1 Million CSL$
Hired/Non-Owned
PHYSICAL DAMAGE
Comprehensive $ (ded.)
Collision $ (ded.)
Downtime/Rental$
Roadside Assistance$
Tow Truck on Hook$
Medical Payments$
Un/Under Insured$
Tow Truck on Hook$
NON-TRUCKING LIABILITY
$1M/2M
TRAILER INTERCHANGE
Fire & Theft $ (ded.)
Fire/Theft/Collision $ (ded.)
Comp/Collision $ (ded.)
MOTOR TRUCK CARGO
$50,000Cargo Deductible:
$100,000$500
$150,000$1,000
$200,000$2,500
$250,000
List All Cargo:
Cargo coverage at a terminal for vehicles left even if overnight or weekends.

*Provide addresses on notes section

OTHER INSURANCE

SCHEDULE OF VEHICLES – List all Vehicles to be quoted.

State of registrationYearMakeVINWho’s Name is vehicle registered underValueGross Weight

DRIVERS INFORMATION:

NameD.O.BCDL License #/State

Notes:

FYI: To obtain a cargo quote we will need driving records not older than 30 days for all listed drivers. Also, please obtain from your current agent a 3-year claim history (loss runs).