Long Haul Trucking
Preliminary Insurance Survey

 

General Information
Company Name :
D. B. A. :
Address :
City :   State :   Zip :
Phone # :   Fax # :
Contact Person :   Title :
E-mail Address :
Website :
How Did You Hear About Us?:


Information About Your Business
# of Years in Business :       # of Tractors :       # of Trailers :
Commodities Hauled :
Radius of Operation :

0-100 miles    101-300 miles
301-500 miles 501+ miles   

DOT Number :
Do you have ICC Authority? Yes    No
Are you leased out? Yes    No


Current Insurance Policy(s) Information
  Current Insurance Co. Expiration Date Premium
Commercial Auto $
Physical Damage $
General Liability $
Cargo
$
Total:
$
Agent/Broker Name :
Address :
City :   State :   Zip :
Phone # :   Fax # :
E-mail :
Contact Person :


Additional Comments



The receipt of a completed survey creates no expressed or implied obligation on the part of Lancer Insurance Company to offer a quotation or provide insurance as requested.

The Preliminary Insurance Survey is copyrighted and material appearing within may not be
reproduced in any form without the written permission of Lancer Insurance Company.

© Lancer Insurance Company, 2008