Workers Comp Insurance Quote 1DOT #2Company Information3Payroll4Owners5Claims6Contact Info What is the name of your company? DOT Number EIN / Tax ID # What do you do? Tractor/trailer: Reefer Tractor/trailer: Dry Van Tractor/trailer: Auto Hauler Tractor/trailer: Flatbed Box Truck Cargo Van Something else? What do you do? Where do you go?Choose all that apply (you can choose more than one)48 States12 WesternAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow many years have you been operating under this business name?How many years have you been operating under this business name?0, this is a new venture12345+How many years have you had prior work comp insurance in your name?How many years have you had prior work comp insurance in your name?0, this is a new venture0, hiring W2 employees for first time12345+What best describes your business's ownership structure? Individual/Sole Proprietor Partnership LLC Corporation Trust Mailing Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What freight do you haul? How many clerical/office employees do you have? (exclude owners/officers)What are the annual wages paid to clerical/office W-2 employees? (exclude owner/officers)How many W2 drivers do you have? (exclude owners/officers)What are the annual wages paid to driver W-2 employees? (exclude owner/officers) Owner(s)First NameLast Name% of Ownership Click on + button on right to add more owners. Prior CoverageEffective DatesInsurance Company Name Any claims last 3 years? Yes No Loss Runs (optional) Drop files here or Select files Max. file size: 200 MB. First Name* Last Name* Email* Phone*Where did you hear about us?*Please select...Google AdGoogle SearchSocial MediaReferralWebsiteOtherQuestions, concerns, special requests?CommentsThis field is for validation purposes and should be left unchanged. Δ Ask a quick question Name* Email* Tell us a bit about your question or request. Δ Meet Chuck Chuck the Truck Duck Call or text: 916-572-9815 chuck@truckduck.com ALEXRUE.com Please refer to the actual policy and/or endorsements for terms, conditions, coverage’s, limitations, exclusions and premium. 916-572-9815 CA License # 0H08143