CTC Transportation Insurance Specialists

CTC Transportation Insurance Services, LLC
12707 High Bluff Drive, Suite 200
San Diego, CA   92130

www.ctcins.com
Use this form to submit your electronic quote request or
       print this form
 and Fax your request to us.

Non-Fleet Quote Sheet

  Underwriter:                Date:     mm/dd/yy

Agency Information

  Agent Code:   Agent Name: State:

  Person to Contact:  

  Proposed Effective Date:    mm/dd/yy or ASAP

Insured Information

  Insured Name:   Owner's Name:

  Address:  

  City:     State:     Zip: 

  Phone:  (xxx)xxx-xxxx       Ext: 

  FAX:  (xxx)xxx-xxxx               Email:

  Insured DOT #:   Brokerage (Y/N)  

  Insured MC 

  CA DMV #: 

  Other State Filings:   Years in Business:

  Does the Insured do Doubles or Triples (Y/N) 

  Radius (give %)  0-100 miles  101-300 miles  301-600 miles  Over 600

  Planning on expanding? (Y/N)    How Much? 

Prior Carrier info for Past 3 Years

Year

Company Name and Policy Number

Losses (Y/N)

Details

Driver Involved

 

 

 

 

Please explain any CANCELLATIONS/NONRENEWAL in the past 3 years:
New Ventures – If no prior insurance in own name, provide 3 years of driver employment history -- LAST 8 MONTHS
Driver Information

Does owner / named insured drive? (if no, explain)

Driver Name

DOB

Licence Number

State

Date Hired

# of Yrs CDL

Last 3 Years Violations

# of Accidents

Vehicle Information
Does risk pull doubles or triples?  Y/N  

Year

Make

Model / VIN

GVW

Present Value

Radius Miles

Comments

Coverage & Limits

Liability

Primary

Non-Trucking

Physical Damage

Deductible

Specified Perils

$

Comprehensive

$

Collision

$

Cargo

Maximum Cargo Limit -->

$

      Cargo Deductible -->

 $ 
Reefer Breakdown? (Y/N)

Commodity Transport

% of Total **

Average $ Value Per Truckload

Max $ Value Per Truckload

                                   ** must add up to 100%

Auto Liability Limits

$

UM

$

UIM

$

PIP Coverage

$

Medical Payments

$

Hired Car

$

Non-Owned

$

GL Coverage

$

Other

$

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