LeBaron Carroll - Quick Trucking App

Form used for general insurance information needed by LeBaron Carroll Insurance to quote trucking insurance
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Enter your legal business name. If that is a DBA, then use that.
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Enter number of years in business rounded to nearest number.
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Percent of Trips:

Enter the percentage of trips your company travels in each of the mileage categories.
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Trucks and Trailers

Truck/Trailer {binding ItemNumber}

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Enter Vehicle Identification Number (VIN)
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Drivers

Driver {binding ItemNumber}

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Any Losses in the Last 3 Years?
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***Optional Coverage***

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LeBaron Carroll - Quick Trucking App

Name of Company
{binding displayValue}
Contact Name
{binding displayValue}
Phone
{binding displayValue}
Email
{binding displayValue}
Business Address
{binding displayValue}
DOT Number
{binding displayValue}
Time in Business
{binding displayValue}
Commodities Hauled
States Most Commonly Traveled

Percent of Trips:

Enter the percentage of trips your company travels in each of the mileage categories.
0-150 Miles
{binding displayValue}
151-300 Miles
{binding displayValue}
301-500 Miles
{binding displayValue}
500+ Miles
{binding displayValue}
{ binding firstError.message }

Trucks and Trailers

Truck/Trailer {binding ItemNumber}

Year
{binding displayValue}
Make
{binding displayValue}
Model
{binding displayValue}
VIN
{binding displayValue}
Stated Value
{binding displayValue}
{ binding firstError.message }

Drivers

Driver {binding ItemNumber}

Name
{binding displayValue}
DL Number
{binding displayValue}
DOB
{binding displayValue}
Years of Experience
{binding displayValue}
{ binding firstError.message }
Current Insurance Carrier
{binding displayValue}
Any Losses in the Last 3 Years?
{binding displayValue}
If 'Yes', explain...

***Optional Coverage***

Cargo Limit
{binding displayValue}
Deductible
{binding displayValue}
Trailer Interchange Limit
{binding displayValue}
{ binding firstError.message }

LeBaron Carroll - Quick Trucking App

Form used for general insurance information needed by LeBaron Carroll Insurance to quote trucking insurance
Name of Company
{binding displayValue}
Contact Name
{binding displayValue}
Phone
{binding displayValue}
Email
{binding displayValue}
Business Address
{binding displayValue}
DOT Number
{binding displayValue}
Time in Business
{binding displayValue}
Commodities Hauled
States Most Commonly Traveled

Percent of Trips:

Enter the percentage of trips your company travels in each of the mileage categories.
0-150 Miles
{binding displayValue}
151-300 Miles
{binding displayValue}
301-500 Miles
{binding displayValue}
500+ Miles
{binding displayValue}
{ binding firstError.message }

Trucks and Trailers

Truck/Trailer {binding ItemNumber}

Year
{binding displayValue}
Make
{binding displayValue}
Model
{binding displayValue}
VIN
{binding displayValue}
Stated Value
{binding displayValue}
{ binding firstError.message }

Drivers

Driver {binding ItemNumber}

Name
{binding displayValue}
DL Number
{binding displayValue}
DOB
{binding displayValue}
Years of Experience
{binding displayValue}
{ binding firstError.message }
Current Insurance Carrier
{binding displayValue}
Any Losses in the Last 3 Years?
{binding displayValue}
If 'Yes', explain...

***Optional Coverage***

Cargo Limit
{binding displayValue}
Deductible
{binding displayValue}
Trailer Interchange Limit
{binding displayValue}
{ binding firstError.message }