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 StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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