Insured’s Name
Street Address
City
County
State
Zip Code
Email
Phone Number
Date of birth (mm/dd/yy)
Employer Identification Number (EIN)
Prior Insurance Carrier, if none, state NONE
Prior BI limits, if none, state NONE
Inception/Effective Date (mm/dd/yy) or NEW
Organization Type Select A Choice Individual/Sole Proprietorship Partnership Corporation
Business Type (e.g. plumber, landscaper, gravel hauler)
Year Current Business Was Established
Does Insured Have a GL or BOP Policy? Select A Choice Yes No
Financial responsibility will be ordered on all risks. For a corporatoin or partnership, use the name of the President, CEO or partner responsible for the daily operatoins of the business.
Driver Information
Year, Make, Model: Vehicle 1 Vehicle 2 vehicle 3 Vehicle 4
Vehicle Type Main Category (Trucks, Trailers, Regular Business, Buses, Motor Homes or Garage Trucks) Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Specific Vehicle Description (e.g. delivery van, box truck, pickup, van, SUV, tow truck, hearse) Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Vehicle Identification Number (VIN) Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Passenger Capacity or # of Axles (for tow trucks, vans, buses ONLY) Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Trailer Hitch? None Vehicle 1 Vehicle 2 Vehicle 3 vehicle 4
Personal Use? None Vehicle 1 Vehicle 2 Vehicle 3 vehicle 4
Garaging Zip Code? Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Total Stated Amount (includes permanantly attached equipment)
Would you like your spouse to be listed as an additional driver? Please Select Yes No
Vehicle #1: Maximum Radius of Operation Please Select 50 100 200 300 500 Unlimited
Vehicle #2: Maximum Radius of Operation Please Select 50 100 200 300 500 Unlimited
Vehicle #3: Maximum Radius of Operation Please Select 50 100 200 300 500 Unlimited
Vehicle #4: Maximum Radius of Operation Please Select 50 100 200 300 500 Unlimited
Bodily Injury/Property Damage Coverage Please Select 15/30/5 25/50/10 25/100/10 50/100/25 100/300/50 250/500/100 35CSL 100CSL 300CSL 500CSL 750CSL 1,000CSL
Uninsured/Underinsured Please Select 15/30/5 25/50/10 25/100/10 50/100/25 100/300/50 250/500/100 35CSL 100CSL 300CSL 500CSL 750CSL 1,000CSL
Personal Injury Protection (PIP) Please Select 15,000 50,000 75,000 150,000 250,000 (Statutory)
PIP Deductible Please Select 250 500 1,000 2,000 2,500
Additional PIP Weekly Benefits (APIP) Please Select $100 $250 $400 $500 $600 $700
Physical Damage Deductible Please Select 100 150 250 500 750 1,000 1,500 2,000 2,500 5,000
Would you like excess liability coverage for any non-owned, unlisted vehicles the business has leased, hired, rented or borrowed? (Hired Auto Coverage) Please Select Yes No
Would you like excess liability coverage for employees using their own vehicles (not listed here) incidentally in the course of the business? Please Select Yes No
Non-Trucking Liability Coverage (“Bobtail/Deadhead Insurance”) Please Select 0 300 CSL 500 CSL 750 CSL 1,000 CSL
Trailer Interchange Coverage Please Select 0 15,000 20,000 30,000 40,000
On-Hook Towing Liability Coverage Please Select 15,000 25,000 50,000 100,000
Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.
Your First Name (required)
Your Last Name (required)
Your Email (required)
Re-Enter Your Email (required)
Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
City (required)
County (required)
State (required)
Zip Code (required)
Question (required)
Phone (required)
