Workers Compensation Quote Request

Company Information
Company Name or D.B.A.
Company Name or D.B.A.
Physical Location of Terminal(s)
Physical Location of Terminal(s)
Please list all terminal locations.
States Where Units are Garaged at Driver's Residence
States Where Units are Garaged at Driver's Residence
Business(es) owned or operated by applicant other than trucking?
Business(es) owned or operated by applicant other than trucking?

Vehicle(s) Information
Number of Tractors
Number of Tractors
Number of Straight Trucks
Number of Straight Trucks
Number of Dump Trucks
Number of Dump Trucks
Number of Cabovers
Number of Cabovers
Number of Wreckers
Number of Wreckers
Other Power Units
Other Power Units
Please list type of unit(s) and quantity.
Please List # of Trailers and Types of Trailers
Please List # of Trailers and Types of Trailers
Examples: Dry Van, Intermodal, Open-Top Van, Flatbed, Tanker, Stepdeck, Hopper Bottom, Reefer, Dry Bulk, Walking Floor, Compressed Gas, Logging, Livestock, Curtain-Side, Auto Transporter/Stinger, Dump, Doubles/Triples, Custom

Additional Information
% of Loading/Unloading with Material Handling Aids
% of Loading/Unloading with Material Handling Aids
% of Tarping Freight By Hand
% of Tarping Freight By Hand
% of Loading/Unloading without Material Handling Aids
% of Loading/Unloading without Material Handling Aids
% of Load Securement using Load-Locks, Bars or, Straps
% of Load Securement using Load-Locks, Bars or, Straps
% of Tailgating Freight
% of Tailgating Freight
% of Decking or Blanket Wrapping
% of Decking or Blanket Wrapping
% of Top-Loading Bulk Tankers (Accessed by Loading Rack)
% of Top-Loading Bulk Tankers (Accessed by Loading Rack)
% of Top-Loading Bulk Tankers (Accessed by Ladder)
% of Top-Loading Bulk Tankers (Accessed by Ladder)
% of Other? (Please describe, if Applicable)
% of Other? (Please describe, if Applicable)

Driver Safety Information
Are certificates obtained?
- Yes
- No
Frequency of Driver Safety Meetings
Frequency of Driver Safety Meetings
Do you have an incentive program for clean inspections?
- Yes
- No
Is there a safety-related incentive program?
- Yes
- No
Does employer use ELDs in units older than 2,000?
- Yes
- No
- Operation Is Exempt

Safety Director's Information
Name of Safety Director
First Name Last Name
Safety Director's Phone
Safety Director's Phone
Safety Director's Email
Safety Director's Email
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This field is for validation purposes and should be left unchanged.

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