General Information

Overland Insurance, Inc.

General Information TRUCK QUOTE First Name Last Name Individual Corporation Partnership Company Name / DBA Address City State Zip Years in Trucking Industry Date Coverage Desired U.S. DOT # MC # Email Phone Fax Operations Data For Hire Private Non-Trucking (bobtail) Do you pull Doubles? Triples? Yes No Yes No Major Cities traveled into or through List all States trucks are operated Cargo Hauled Cargo Value Loss Experience Any Losses in the last 3 years? Please list insurance history and any losses you have had for the last 3 years. 3 years of insurance company loss runs will be required in order to place coverage after we quote. Yes No Dates of Coverage Company Policy Coverage # of Losses Loss Type Loss Amount Number Driver Information Name Date of Birth License # Hire Date Experience # Accidents Last 3 Years # Years of # Violations Last 3 Years Schedule of Equipment Year Make Body Type Serial Number Gross Radius Value Loss Payee Weight Coverages and Limits Liability Non-Trucking Liability Physical Damage Deductible: Comprehensive Collision Cargo Limit Cargo Personal Injury Protection (Washington State Only) Uninsured / Underinsured Motorists Coverage