OLQuote - Online Insurance Quote

Company Name*

DBA Name :

Phone Number*

Email Address*

Website, if any (preferred):

Please mention the date, month and year the business began operating under your current DOT #*

DOT Number*

MC Number(preferred):

Business EIN (preferred):

Policy Effective Date :

What is the insured’s garage state?

Is the customer currently insured with Commercial Auto?

Yes No

Mailing Address -

Address:

(Mailing address/garaging address must match FMCSA/SAFER records for filing to be processed)

Address Line 2:

City:

State:

ZIP Code :

Business Garaging Address -

Address:

Address Line 2:

City:

State:

ZIP Code :

Terminal Address -

Address:

Address Line 2:

City:

State:

ZIP Code :

Business Owner Information –

(PLEASE USE THE PHYSICAL ADDRESS LISTED ON THE INSURED’S SAFER)

Owner First Name*

Owner Last Name*

Date of Birth*

Owner License No.*

Owners License State*

Owners Address (if different from business address) -

Address:

Address Line 2:

City:

State:

ZIP Code :

Business Type*

(Example – Trucker, Landscaper, Janitorial, Hotshot)

Exact Years in Business:

What kind of entity is your business?*

Best description of your operation* (Choose any that apply)

Telemetry Data Sharing- ELD and Dash Camera –

To enhance driving safety and affordability, Nirvana and Cover Whale quotes require a data sharing method. Please answer the following about the insured’s current setup.

Data Sharing Option

Who is the insured ELD/Dash Camera Provider? (required for Nirvana)

Driver Information -

First Name	Last Name	DOB	DOH	Experience	Licdense State	License No	CDL	Accidents	Violations	Suspensions	Comment	Action

Vehicle Information -

Year	Make	Model	VIN	Value	Body Type	Class	Hitch Type	APD/Towing Coverage	Ownership	Action

Trailer Information -

Year	Make	Model	VIN	Value	Body Type	Ownership	Action

Coverages (Select Coverage the Customer wants)

Is the customer currently insured?

Yes No

Has the customer had continuous coverage?

Yes No

Auto Liability (AL):

Rental Requirement

Roadside Assistance

Hired Auto Liability

Is a Blanket Additional Insured endorsement needed by contract?

Motor Truck Cargo (MTC)

Automobile Physical Damage (APD)

Truckers General Liability (TGL)

Non-Trucking Liability (NTL)

Does the Insured Required Non-Owned Trailer Coverage?

Number of Non-Owner Trailers:

Body Type:

Value:

Amount of Non-Owned Trailer Coverage

Deductible

Limits

Towing, Labor, and Storage Limit *

Cargo

Commodity Type	Percentage	Refrigerated	Action

Radius -

Under 50 miles (Max 100%)

51-200 Miles (Max available 100%)

201-500 Miles (Max available 100%)

500+ Miles (Max available 100%)

Total: 0%

Interstate or Intrastate?

Interstate Intrastate

Do any vehicles cross state lines?

Yes No

Annual Mileage*

Gross Sales Annual*

Total Payroll*

Number of Employees*

Losses (Last 3 years)

(Reporting period: from the current date back to the same date one year earlier. Repeat similarly for the previous two years to cover the last 3 years.)

Auto Liability: Loss Count (Open or Closed)

Auto Liability: Losses paid (Open or reserved)

Physical damage: Loss Count (Open or Closed)

Physical damage: Losses paid (Open or reserved)

Cargo: Loss Count (Open or Closed)

Cargo: Losses paid (Open or reserved)

Truckers general liability: Loss Count (Open or Closed)

Truckers general liability: Losses paid (Open or reserved)

Start Date	End Date	Auto Loss Count	Auto Loss Paid	Physical Damage Loss Count	Physical Damage Loss Paid	Cargo Loss Count	Cargo Loss Paid	Truckers General Liability Loss Count	Truckers General Liability Loss Paid	Action

Do you need to list any loss payees?

Yes No

Vehicle/Trailer details:

Note, if any:

Note, if any for Licensed Agent or Underwriter:

Attach documents, if any. (Example- Copy of Drivers License, Copy of Drivers Commercial License, Copy of Current Certificate of Insurance, Loss Reports, etc.)

Loss Report*

No File Chosen (Max 2 MB)

Driver's License

No File Chosen (Max 2 MB)

Driver's Commercial License

No File Chosen (Max 2 MB)

Certificate Of Insurance

No File Chosen (Max 2 MB)

Target premium, if any:

When the Power Unit to Driver ratio does not match SAFER records, please provide a brief explanation below.

Summary Account:

Commercial Trucking Insurance

Mailing Address -

Business Garaging Address -

Terminal Address -

Business Owner Information –

Owners Address (if different from business address) -

Telemetry Data Sharing- ELD and Dash Camera –

Driver Information -

Vehicle Information -

Trailer Information -

Coverages (Select Coverage the Customer wants)

Limits

Cargo

Radius -

Losses (Last 3 years)

(Reporting period: from the current date back to the same date one year earlier. Repeat similarly for the previous two years to cover the last 3 years.)

Call Us - 888-418-0865

Commercial Trucking Insurance

Mailing Address -

Business Garaging Address -

Terminal Address -

Business Owner Information –

Owners Address (if different from business address) -

Telemetry Data Sharing- ELD and Dash Camera –

Driver Information -

Vehicle Information -

Trailer Information -

Coverages (Select Coverage the Customer wants)

Limits

Cargo

Radius -

Losses (Last 3 years)

(Reporting period: from the current date back to the same date one year earlier. Repeat similarly for the previous two years to cover the last 3 years.)

Add Driver

Add Vehicle

Add Trailer

Add Commodity