First Name:
*
Last Name:
*
Email:
*
Phone:
*
Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Owner License Number/ State:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Garaging Address (if different):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Business name (If not yet official, put what it will be named):
*
DOT Number, if known:
*
Radius of driving operations in miles:
*
Any tickets, accidents, or suspensions in the last five years?
*
Yes
No
Do you have CDL, if so, how long ago was it issued?
*
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Do you have personal car insurance?
*
How soon are you looking to start your insurance program?
*
Year/Make/ Model/ Value of truck. If leasing and you don't yet know the details, just put "leasing"
*
Do you have a lift gate or any other permanently attached equipment? If so, how much is it worth?
*
Business Operations (click all that apply)
Amazon Relay
Tractor Trailers
Hot Shot
Box Truck
Cargo Van
Refrigerated Loads
UIIA (Intermodal)
Describe your commodities:
*
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Names, DOB, years of experience, and license numbers/license states of drivers:
What experience do you and your drivers have driving similar equipment?
*
Do you currently have a trucking insurance policy?
*
Yes
No
Is your current policy with Progressive?
*
Yes
No
How much are you paying now for that policy?
*
What has been your biggest problem so far with insurance? (We really like to solve problems!)
Are there any contracts you need specific coverage for?
Anything else we should know?
Consumer Reports
*
I authorize Red Rose Insurance, LLC to run Financial Responsibility Reports.
Texts and Email
*
I authorize Red Rose Insurance, LLC to send me automated texts and emails.
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If you have it, upload current policy, MVR, or copy of Loss Runs.
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