Request a Free Quote

* Indicates a required field

Company Name:   
Last Name: * 
First Name: * 
Street Address: * 
City: *     State:*     Zip:*  
Best Contact #: *  E-mail: *

Equipment Year and Make

Total # of  Trucks:*          1-5     6+ (Fleet Policy An agent will contact you for additional information.)
 
Year
Vehicle Make
Value
Unit1

Unit2
Unit3
Unit4
Unit5

Driver Information

Total # of  Drivers: *     1-5    6+ (Fleet Policy An agent will contact you for additional information.)
  Driver's Age Tickets or Accidents *  Years w/ CDL
Driver 1

 

 

Driver 2  

 

Driver 3  

 

Driver 4  

 

Driver 5  

 


Insurance Information

Limits of Liability:

Amount of Cargo Insurance:

Type of Cargo Hauled:

(Please check all that apply.)
Building Materials / Heavy Equipment
Refrigerated Goods: Produce, meats, etc
Automobiles / Boats
Mobile Homes
Household Goods
Dry Goods: Grocery, Paper, Plastics
Target Items: Electronics, clothing, alcohol, shellfish
Other - Please explain

(if Other):

Radius:


Have you had any paid claims in the last 36 months? Yes No
Please check off any additional coverage required:
General Liability Truckers Occupational
Trailer Interchange Workers Compensation
If FMCSA Filings are required, fill in MC #:      
Anticipated Date you will need this insurance:       

Where did you hear about us?

Questions or Comments:

 


Please type southatlantic into the field above
to validate your form submission:

 

 

 

 

 
 
 
South Atlantic Insurance Services

South Atlantic Insurance Services

7451 Wiles Rd., Suite #103 • Coral Springs, FL 33067
Phone: (954) 755-8577 • Toll-Free: (800) 613-1093 • Fax: (954) 755-9556

Florida Trucking Association member