FEATURED SERVICES
 • Truck Insurance Quote Form
 • Commercial Auto Quote Form

 • Request for Certificate of Insurance
 • Add / Remove a Driver Request
 • Auto ID Request Form
 • Add a Vehicle Request
 • Remove a Vehicle Request


  ♦  Primary liability 
  ♦  Bobtail 
  ♦  Gross receipts & mileage
  ♦  Physical damage 
  ♦  Trailer interchange 
  ♦  Fuel-Tax & Licensing  
  ♦  Registration Services




Truck, Trucking & Truckers Insurance Quote

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  
Garage Address:  
Owner/President:  
Safety Manager:  
Years in Business:  
Other Manager:  

Policy Information
Limits of Liability:
Inception Date:  
Primary:  
Deductibles:       
UM / UIM:  
Comp:  
PIP / Medical:  
Coll:  
GL:  
Physical Damage:      
Cargo Limit:  
Tractor Values:  
Terminal Address:  
Trailer Values:  
Hired Auto Required:  
Policy Cancellation/Non-renewal last 5 years:  

Operations
FHWA Docket #:  
USDOT #:  
Brokerage Name:  
Docket #:  
Brokerage/FF Revenue (this year):  
Estimate for Next Year ($):  
Current DOT Rating & Date:  

Percentage of Radius of Operations
0-75:  301-500: 76-100:  500-1000: Unlm:
Regular Routes:  
Major Metro Areas:  
Major Shippers:

Commodities Hauled
Commodity
% Hauled
Average Value
Maximum Value

Revenue/Mileage History
Yearly Estimates
Mileage
Revenue
# Units
For Year b/f last:  
For Last Year:  
For Coming Year:  

Equipment
# Tractors
# of Trailers
# of Service Units
Owned:  
O / O:  

Add any additional comments or information that may assist us in your quote below:

Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentially viewed by unauthorized others. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Dixon Insurance, Inc. | Interstate Truck Licensing, PO Box 10307, Fargo, ND, 58106  Ph: 800-258-5369  e-mail us


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