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Select Coverage







Auto Liability insurance protects you when a third party is injured in an accident.






Physical damage is a general term for a group of insurance coverages that protect your vehicle.







General liability can protect you from a variety of claims including bodily injury, property damage, personal injury and others that can arise from business operations.







Motor truck cargo insurance provides coverage for the damage or loss of freight in transit.






Medical, disability, death and dismemberment benefits for accidents that occur on the job.

Avery Brookes - Create a Quote


Policy Info





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Commodity #{{com.id}}

{{CommodityErrorMsg}}


Auto Liability


Cargo Insurance


Commodity
%
{{ com_info.name}} {{ com_info.value }}



Requested Limits of Liability:

Requested Deductible:

Details of Current Motor Truck Cargo:

Motor Truck Cargo Rater

History:

Upcoming Year:

Current Year:

First Prior:

Second Prior:

Third Prior:

Fourth Prior:

Loss History

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(From)
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(To)
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Terminal Locations :









Additional Underwriting Questions

General Liability


Physical Damage/NTL


Vehicle Physical Damage Rater

{{quote.physicaldamage.AveragePowerUnitValue}} %
{{quote.physicaldamage.MVRAvgDri}}
{{quote.physicaldamage.AtFaultAccidents}}
{{quote.physicaldamage.annualrate}}% ${{quote.physicaldamage.annualp}}

Non Trucking Liability Limit

${{quote.physicaldamage.State}}
${{quote.physicaldamage.MonthlyRate}} ${{quote.physicaldamage.AnnualPremiumunit}}

Occupational Accident



Driver #{{occaccinfo.id}}

Check One



Independent Contractor Information :
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Independent Contractor Information :



Have you had any of the following:

Driver Information



Add Driver


Driver #{{driverinfo.id}}

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{{NewDriverErrorMsg}}


Add Vehicle


Vehicle #{{vehicle.id}}

{{NewVehicleErrorMsg}}


Loss Runs and MVRs


Document #{{bp.index}}




Prior Insurance Information


Add Prior Insurance

Prior Insurance Info #{{priorinfo.id}}

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Policy Info    Edit

{{quote.generalinfo.name}}
{{quote.generalinfo.contactname}}
{{quote.generalinfo.email}}
{{quote.generalinfo.phone}}
{{quote.generalinfo.address}}
{{quote.generalinfo.city}}
{{quote.generalinfo.state}}
{{quote.generalinfo.zip}}


{{quote.generalinfo.dotno}}
{{quote.generalinfo.mcmxno}}
{{quote.generalinfo.feinno}}
{{quote.generalinfo.business_type}}
{{quote.generalinfo.business_started_date_month}}/{{quote.generalinfo.business_started_date_day}}/{{quote.generalinfo.business_started_date_year}}
{{quote.generalinfo.desired_from_date_month}}/{{quote.generalinfo.desired_from_date_day}}/{{quote.generalinfo.desired_from_date_year}} To {{quote.generalinfo.desired_to_date_month}}/{{quote.generalinfo.desired_to_date_day}}/{{quote.generalinfo.desired_to_date_year}}


{{quote.generalinfo.metro_selected}}
{{quote.generalinfo.other_city}}


{{quote.generalinfo.leased_to_user}}
{{quote.generalinfo.is_leased_to}}
{{quote.generalinfo.leased_to}}


(0-75 miles) {{quote.generalinfo.round_trip_1}}%, (76-200 miles) {{quote.generalinfo.round_trip_2}}%, (201-500 miles) {{quote.generalinfo.round_trip_3}}%, (>500 miles) {{quote.generalinfo.round_trip_4}}%

Name Value
{{ com_info.name }} {{ com_info.value }}

No Commodities added



Auto Liability    Edit

{{quote.autoliability.type}}
{{quote.autoliability.limit}}
{{quote.autoliability.trailer_interchange}}
{{quote.autoliability.limit_per_trailer}}

${{quote.autoliability.ti_deductible}}
{{quote.autoliability.no_of_trailers}}
{{quote.autoliability.hired_auto}}  
{{quote.autoliability.hire_anual_cost}}

{{quote.autoliability.brokerage_auth}}
{{quote.autoliability.brokerage_docket_no}}
{{quote.autoliability.brokerage_revenue}}

{{quote.autoliability.um}}
{{quote.autoliability.pip}}

Physical Damage/NTL    Edit

${{quote.physicaldamage.deductible}}

Vehicle Physical Damage Rater

{{quote.physicaldamage.powerunitcount}}
${{quote.physicaldamage.totalpowerunit}}
${{quote.physicaldamage.avgpowerunitvalue}}
{{quote.physicaldamage.AveragePowerUnitValue}}
{{quote.physicaldamage.MVRAvgDri}}
{{quote.physicaldamage. AtFaultAccidents}}
{{quote.physicaldamage.trailerUnitcount}}
${{quote.physicaldamage.TotTrailerVal}}
${{quote.physicaldamage.TotInsuredVal}}
{{quote.physicaldamage.deductible}}
{{quote.physicaldamage.annualrate}}
{{quote.physicaldamage.annualp}}

Non Trucking Liability Rater

${{quote.physicaldamage.NonTrucliab}}
{{quote.physicaldamage.State}}
{{quote.physicaldamage.MonthlyRate}}%
{{quote.physicaldamage.AnnualPremiumunit}}

General Liability    Edit

{{quote.generalliability.limit}}
{{quote.generalliability.other}}
{{quote.generalliability.other_details}}

Cargo Insurance    Edit

{{quote.cargoinsurance.safety_director}}
{{quote.cargoinsurance.federal_filing}}
{{quote.cargoinsurance.state_filing}}
{{quote.cargoinsurance.property_covered}}
${{quote.cargoinsurance.average_load}}
${{quote.cargoinsurance.maximum_load}}
{{quote.generalinfo.perils_selected}}

Requested Limits of Liability :

${{quote.cargoinsurance.vehicle}}
${{quote.cargoinsurance.cleanup}}
${{quote.cargoinsurance.disaster}}
${{quote.cargoinsurance.freight}}
${{quote.cargoinsurance.terminal}}
${{quote.cargoinsurance.debris}}

Requested Deductible :

${{quote.cargoinsurance.occurence}}
${{quote.cargoinsurance.refrigeration}}
${{quote.cargoinsurance.theft}}

Details of Current Motor Truck Cargo :

${{quote.cargoinsurance.carrier}}
${{quote.cargoinsurance.renewal}}
${{quote.cargoinsurance.current_rate}}
${{quote.cargoinsurance.current_premium}}

History:

Upcoming Year:

{{quote.cargoinsurance.upcoming_year_duductibles}}
{{quote.cargoinsurance.upcoming_year_own_haul}}
{{quote.cargoinsurance.upcoming_year_subcontracted}}
{{quote.cargoinsurance.upcoming_year_unit_count}}

Current Year:

{{quote.cargoinsurance.current_year_duductibles}}
{{quote.cargoinsurance.current_year_own_haul}}
{{quote.cargoinsurance.current_year_subcontracted}}
{{quote.cargoinsurance.current_year_unit_count}}

First Prior:

{{quote.cargoinsurance.first_prior_duductibles}}
{{quote.cargoinsurance.first_prior_own_haul}}
{{quote.cargoinsurance.first_prior_subcontracted}}
{{quote.cargoinsurance.first_prior_unit_count}}

Second Prior:

{{quote.cargoinsurance.second_prior_duductibles}}
{{quote.cargoinsurance.second_prior_own_haul}}
{{quote.cargoinsurance.second_prior_subcontracted}}
{{quote.cargoinsurance.second_prior_unit_count}}

Third Prior:

{{quote.cargoinsurance.third_prior_duductibles}}
{{quote.cargoinsurance.third_prior_own_haul}}
{{quote.cargoinsurance.third_prior_subcontracted}}
{{quote.cargoinsurance.third_prior_unit_count}}

Fourth Prior:

{{quote.cargoinsurance.fourth_prior_duductibles}}
{{quote.cargoinsurance.fourth_prior_own_haul}}
{{quote.cargoinsurance.fourth_prior_subcontracted}}
{{quote.cargoinsurance.fourth_prior_unit_count}}

Policy Term (From) Policy Term (To) Valuation Date Carrier # Of Claims Total Incurred Premium
{{ loss.policy_from_date_month }}/{{ loss.policy_from_date_year }} {{ loss.policy_to_date_month }}/{{ loss.policy_to_date_year}} {{ loss.valuation_date_month }}/{{ loss.valuation_date_day }}/{{ loss.valuation_date_year }} {{ loss.carrier }} {{ loss.claims }} ${{ loss.incurred }} ${{ loss.premium }}

No Loss History added

Terminal Locations:

Terminal Address Max. Value Exposed Security Type
{{tloc.terminal_address}} {{tloc.max_exposed}} {{tloc.alert2_selected}}

No Terminal Location added

{{quote.cargoinsurance.premium_ad}}

Additional Underwriting Questions

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{{quote.additonalques.Q10}}
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{{quote.additonalques.Q12}}
{{quote.additonalques.Q13}}

Occupational Accident    Edit


Driver #{{occaccinfo.id}}

Policy : {{occaccinfo.check1}}

Independent Contractor Information :
{{occaccinfo.name}}
{{occaccinfo.ssfein}}
{{occaccinfo.address}}
{{occaccinfo.CDL}}
{{occaccinfo.city}}
{{occaccinfo.state}}
{{occaccinfo.zip}}
{{occaccinfo.yrexp}}
{{occaccinfo.dob_month}}/{{occaccinfo.dob_day}}/{{occaccinfo.dob_year}}
{{occaccinfo.gender}}
{{occaccinfo.email}}
{{occaccinfo.homephone}}
{{occaccinfo.cellphone}}
{{occaccinfo.Beneficiary}}
{{occaccinfo.relBeneficiary}}



Independent Contractor Information :
{{occaccinfo.paidby}}
{{occaccinfo.owntruck}}
{{occaccinfo.leasetruck}}
{{occaccinfo.optruck}}
{{occaccinfo.optruckdetail}}
{{occaccinfo.optruckcodr}}
{{occaccinfo.optruckcodrdetail}}
{{occaccinfo.eqptype}}
{{occaccinfo.eqptypedetail}}
{{occaccinfo.occclaim}}
{{occaccinfo.occclaimdetail}}
{{occaccinfo.fillbank}}
Have you had any of the following:
{{occaccinfo.hitrun}}
{{occaccinfo.Fleeing}}
{{occaccinfo.Manslaughter}}
{{occaccinfo.DUI}}
{{occaccinfo.felony}}
{{occaccinfo.Racing}}
{{occaccinfo.suspended}}
{{occaccinfo.Reckless}}

Driver Info    Edit

{{quote.driver_info.min_age}}
{{quote.driver_info.min_exp}}
{{quote.driver_info.min_violation}}

Name State Lic. No. Years of Exp. Married MVR Violation
{{ driver_info.name }} {{ driver_info.state }} {{ driver_info.licno}} {{ driver_info.years_exp }} {{ driver_info.married }} {{ driver_info.mvr_violation }}

No Driver Info added

Vehicle Info    Edit

{{quote.power_unit_own}}
{{quote.power_unit_details}}

VIN Year Make Model Radius Stated Amt. Garage City Garage State Loss Payeee Name Loss Payeee Address Loss Payeee City Loss Payeee State Loss Payeee Zip Code
{{ vehicle.vehicle_no }} {{ vehicle.year }} {{ vehicle.make }} {{ vehicle.model}} {{ vehicle.radius }} {{ vehicle.stated_amt }} {{ vehicle.garage_city }} {{ vehicle.garage_state }} {{ vehicle.loss_payee_name }} {{ vehicle.loss_payee_mail_address }} {{ vehicle.loss_payee_city }} {{ vehicle.loss_payee_state}} {{ vehicle.loss_payee_zip }}

No vehicles added

Type Attachment
{{ bp.bp_type }}

No Document added

Prior Insurance Info    Edit

{{quote.prior_cancel_details}}

Policy No. Valid From Valid From Insurance Company Service Type Bodily Injury Property Damage Collision Other Damage Cargo
{{ priorinfo.policy_no}} {{ priorinfo.from_date_month }} / {{ priorinfo.from_date_day }} / {{ priorinfo.from_date_year}} {{ priorinfo.to_date_month }} / {{ priorinfo.to_date_day }} / {{ priorinfo.to_date_year}} {{ priorinfo.company }} {{ priorinfo.type }} {{ priorinfo.bodily_injury }} {{ priorinfo.property_damage }} {{ priorinfo.collision }} {{ priorinfo.other_damage }} {{ priorinfo.cargo }}

No Prior Insurance Info added


If all of the above the information are correct, then kindly submit the form

I authorize W. E. Love & Associates and/or the producing broker to obtain proper cop(ies) of Motor Vehicle Report(s) and Insurance Scoring information for insurance underwriting purposes for all drivers listed and/or any drivers who will operate equipment covered under any prospective insurance policy for which this application relates. All drivers have or will authorize me to consent the same. I certify that all application information is true and agree that any misrepresentation by me will constitute reason for the company to void or cancel any policy issued on the basis of the application, and will hold the company harmless for the action taken.

I have read and agree to the Terms & Conditions.