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Who referred you to us?

Name *

Client's Name:

Company Name (DBA)

Phone Number *

Email Address *

Street Address *

City *

State *

ZIP Code

Type of Entity *

Commodities hauled and percent of each (if fertilizer, list chemical name and if it is bulk, bagged or liquid)

Oversized Loads

MC# Type

MCS-90

Yes

No

MC#

Exempt Filings *

US DOT #

If new venture, list employment references for last 3 years

Radius *

States Traveled

Cities Entered

Insurance carriers, last 3 years

Current Carrier

Exp. Date

1st year prior

2nd year prior

Past Claims (describe)

How many vehicles in your fleet?

Unit #s

List Year, Make, Type/Model, GVW and stated value of each vehicle

Trailer types (Dumps, Hopper Bottom, Van Lowboy, etc.)

Ever hire, rent or borrow any tractors or trailers?

Yes

No

If yes, list value and what type

Driver Names and # of years commercial driving experience

Liability Limit: $ of Requested Coverage *

Uninsured motorist limit request

Personal injury (PIP) Requested

Full

Partial

Lease or Contract Company Name (Required for non-trucking quote)

Physical Damage Less Deductibles, Comprehensive *

Physical Damage Less Deductibles, Collision *

Cargo *

Per-load Deductible *

Reefer Deductible *

Average Value per Load

Maximum Value

General Liability *

***Certain individuals associated with Alera Group, Inc. and its subsidiaries are registered to offer investment advisory services and offer securities. For each individual’s registration status, please view their individual website and disclosures. Additional information about individuals registered with FINRA can be found on FINRA's BrokerCheck

**We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

By submitting this form, you authorize the information to be provided to Alera Group and its subsidiaries (collectively "Alera") and agree Alera may contact you utilizing the contact information provided.

Contact us by phone at 410-820-7797 or 800-235-9885, in person or by mail at 28640 Marys Ct., Suite 100, in Easton, or by submitting a secure message below.

Our hours of operation are Monday - Friday 8:00 a.m. - 4:30 p.m.