Info Needed For Quote : NTA Insurance, Insurance That Drives the Country

Info Needed for Quote

* Required information

Name: *
Phone: *
Fax:
Email:

Equipment List Equipment Option 1. Equipment Option 2. Equipment Option 3. Equipment Option 4. Equipment Option 5.

Drivers List Driver 1. Driver 2. Driver 3. Driver 4. Driver 5.

Date of Hire:
Loss runs for last 3 years:

Copy of last 4 Quarterly IFTA Reports. These can be submitted when we contact you.

Owner Info

Date of Birth:

Federal ID Number:
or (DL# and SS#):

MC number:
DOT number:
Federal ID Numbers:
Number of years in the trucking business? (Include any Previously Owned Trucking Companies):

Do you use electronic Logs?: *

Do you use a GPS Tracking system for loads or Power units?: *

Commodities you are hauling:

Do you need Terminal Coverage?: *

If you need terminal coverage please provide address of each terminal location:

Cargo limit amount:

Deductible amounts for APD (Automobile Physical Damage):

Deductible amounts for MTC (Motor Truck Cargo):

Do you carry contracts with any shippers?: *

If yes What are the names of the company(s) you haul for?:

If yes Are there any dedicated routes?: *

If there are dedicated routes, What are the loading and destination points?:

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