Auto Quote Sheet

Commercial Auto Quick Quote Sheet

JAEGER + HAINES, Inc.    Watts 1-800-632-0342    Fax 479-521-3195

To be used for quoting purposes only and is NOT an application for coverage.

Agency    Phone:

Contact    Fax:

Name:    Quote Needed By Date: not ASAP

Individual Partnership Corporation

Garaging Location(s)    Current Policy Expiration Date:

City:    State:    Zip:    Current Pricing:

Description of Operations:

   For Hire    Not For Hire

How many years with truck insurance in your name?    How many years experience in trucking industry?

Named Insured’s DOT#    MC#

Yes / No Questions

1. Are filings required? If yes, list major cities traveled through or into

Yes No

2. Do you transport anhydrous ammonia, explosives, gasoline, LPG, acids or chemicals? Yes No

3. Is all equipment owned by you scheduled below? If no, explain. Yes No

4. Have you had any policy cancelled or non-renewed in the past 3 years? If yes, give reason. Yes No

5. Do you pull double or triple trailers? Yes No

Driver Information

Must be completed for all drivers. (If additional space is needed, attach a separate list)

Schedule of Autos

(If additional space is needed, attach a separate list)

*Body Type = Truck, Tractor, Semi-Trailer, Trailer or Utility Trailer. **(GVW) = Gross Vehicle Weight or (GCW) = Gross Combined Weight.

Commodities Transported

Prior Carrier Info. (past 3 years)

Please provide details of losses including both “At Fault” and “Not At Fault”.

Coverages

(Scheduled Autos)