Commercial Auto/Trucking Discovery Step 1 of 10 - Personal Info 10% Contact Person(Required) First Last Is the contact person the business owner or president?(Required) Yes No Business Name (if different than Contact Person) Organization Type:(Required)Individual/Sole ProprietorLLC/PartnershipCorporationFEIN:Cell Phone(Required)Please provide the best contact phone number where we can reach you to discuss your quote and send you text updates.Email(Required) Please provide the best email address for us to send the insurance quote.Mailing Address(Required) 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 What is the reason you are shopping your insurance?(Required)Please check all that apply Price Service Bad Claims Experience COI Issues Other How did you first hear about us?(Required) Current Personal Lines Client Client Referral Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other Please tell us more about why you're looking for new insurance:(Required) Is mailing address the same as business's physical address? Yes No Do you have a DOT# / MC# or plan to get one in the next 6 months?(Required) Yes No Loss Run Reports(Required)Do you agree to help us obtain a copy of your current loss run history report showing any losses/claims for the last 5 years? Yes No DOT #(Required)If unavailable or not applicable, enter: "N/A" MC #(Required)If unavailable or not applicable, enter: "N/A" Date Business Started:(Required) Years of Experience:(Required) Estimated upcoming annual gross sales/revenue:(Required)Briefly describe your operations:(Required) Owner/President's Name(Required) First Last DOB:(Required) MM slash DD slash YYYY Home Address(Required) 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 Business Physical Address(Required) 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 list the type of cargo being carried and percentage:(Required)Example: "Raw Construction Materials / 30%" Use the "+" to add more lines as needed. Add Remove Auto Limits RequestedAuto Liability Limit:(Required) Uninsured/Under-insured Motorist Coverage(Required) Do Not Include Include Limit Requested(Required) Personal Injury Protection(Required) Do Not Include Include Limit Requested(Required) Filings Required(Required) No Yes Filing Type(Required) Hired/Non-owned Auto Required(Required) Do Note Include Include Limit Requested(Required) Cargo Coverage Requested(Required) Do Not Include Include Limit Requested(Required) Trailer Interchange Required(Required) Do Not Include Include # of Trailers(Required) Roadside Assistance(Required) Do Not Include Include Current GL/BOP policy in force:(Required) Yes No Interested in Telematics Discount(Required) Yes No Any additional coverage notes, requests, requirements Current CoverageCurrent/expiring carrier name:(Required) How long have you been with the current carrier?(Required)New VentureBetween 1 and 3 yearsBetween 3 and 5 yearsMore than 5 yearsPolicy Term:(Required) Expiring Premium:(Required) Drivers InformationDo you want to provide a list of drivers or email a list of drivers?(Required) Email/upload drivers list Provide list Driver's Name / TXDL # / DOB/ Marital Status / Date of Hire / Yr of CDL Endorsement(Required) Add Remove Vehicle/Trailer InformationDo you want to provide a list of vehicles/trailers or email a list of owned vehicles?(Required) Email/upload vehicles list Provide list Year / Make / Model / VIN / Value / Radius Driven Add Remove Authorization(Required) I agree & consent to the following:All the information is true and correct to the best of my knowledge. By submitting this request you are authorizing My Insurance Group, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
