Cooper Insurance & Associates
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Please fill out the information below to receive your free quote!

*Signifies a required field below

DATE:
*APPLICANT: (Individual Name/Owner)
* EMAIL ADDRESS
* PHONE #:
CELL #:
D/B/A:
GARAGE ADDRESS:
Street: City: State: Zip:
(Where you park your trucks)
*COVERAGE NEEDED:
Primary Coverage Liability
  Physical Damage
  Cargo
  OR
Non-Trucking(Bobtail) and Physical Damage
LIABILITY LIMITS:
Amount: Other: ICC/FHWA Filings:
MC#:
DOT#:
GA MCA#:
OTHER COVERAGES:
Hired Auto:
Non-Owned Trailer:
General Liability:
 
RADIUS: (Furthest Destination)
STATES TRAVELED:
CITIES TRAVELED:
CARGO LIMIT:
Amount: Other: (Keep in mind that most shippers
will require a $100,000 limit)
COMMODITIES:
#1:
#2:
#3:
#4:
Commodities: %: Value of Avg. Load: Max value of Load:
(Example: Lumber 45% $30,000 $50,000
YEARS IN BUSINESS:
EXPIRATION DATE:
PRIOR CARRIER INFO:
1st Year:
2nd Year:
3rd Year:

Dates: Insurance Co: Claims/Losses: Amount Paid:
3 YR HISTORY (if you did not have insurance in your name, please indicate
companies that you were leased on, or companies for which you were a driver)
VEHICLE SCHEDULE:
#1:
#2:
#3:
#4:
#5:
#6:
#7:
#8:
#9:
#10
Year: Make/Model: Radius: GVW: Value: Deductible:
 
DRIVER INFO:
#1:
#2:
#3:
#4:
#5:
#6:
#7:
#8:
#9:
#10:
Name: DOB: Yrs w/ CDL: Date of Hire: Violations:  
 
 
 
 
 
 
 
 
 
 
(Try to be as specific as possible when reporting violations! Give dates, and if speeding, give how much over posted limit. We need prior three year history.)
HOW DID YOU FIND US? 
COMMENTS: 
 

 

2011. Venza Group, Inc.
All rights reserved.
 
810 Rock Quarry Road, Stockbridge, GA 30281 (770)389-0089