Home   |   Used Trucks and Trailers   |   New Trailers   |   Financing   |   Insurance   |   Contact Us

Republic Insurance Group Trucking Insurance Application

Please fill out the form below to move to the second page. Use the TAB key to move ahead, and SHIFT-TAB to move back a field. If you NEED ASSISTANCE, call 1-866-431-7447 and we will fill this form out for you. Fields marked with a RED ARROW are required and must not be skipped if you desire a quick quote!

Name > Required
Business name
Address > Required
City > Required
State > Required
Zip > Required
ICC or MC#
DOT#
Authority >
Freight hauled > (for ex. 50% steel, 50% plastic pipe)
Phone # >
Years in business >
Current Insurer > Company / exp. date
Liability 0 if none required
Bobtail 0 if none required
Physical damage deductable 0 if none required
Cargo 0 if none required
Cargo deductible 0 if none required
Radius > (ex. 300 mi)
Major cities traveled > (ex. Cincinnati, Cleveland, Lexington)
   

Please list all drivers below. Use TAB to move between fields and SHIFT-TAB to go back a field. You must have at least 1 driver to go to the last page and list your equipment. If there is not enough space below, fax your driver list to 859-342-8606
Driver #1 name >
#1 Social >
#1 Date of birth >
#1 License # & state >
#1 Hire date / yrs experience > (ex. 05/01/99 - 10yr)
#1 Accidents/tickets > Past 3 years
Driver #2 name
#2 Social
#2 Date of birth
#2 License # & state
#2 Hire date / yrs experience (ex. 05/01/99 - 10yr)
#2 Accidents/tickets Past 3 years
Driver #3 name
#3 Social
#3 Date of birth
#3 License # & state
#3 Hire date / yrs experience (ex. 05/01/99 - 10yr)
#3 Accidents/tickets Past 3 years
   

Equipment list

Use the TAB key to move between fields, use SHIFT-TAB to back up a field. Hit submit at the bottom of the page. We will forward your information to several companies, advising you of the best rate. If you have more equiptment that won't fit in the space provided, please fax your list to 859-342-8606.
Veh #1 year >
Veh #1 make > (ex. Kenworth)
Veh #1 GVW > (ex. 80,000) or TL for trailer
Veh #1 VIN > 17 digits
Veh #1 Value leave blank if no physical damage reqd
Veh #2 year
Veh #2 make (ex. Kenworth)
Veh #2 GVW (ex. 80,000) or TL for trailer
Veh #2 VIN 17 digits
Veh #2 Value leave blank if no physical damage reqd
Veh #3 year
Veh #3 make (ex. Kenworth)
Veh #3 GVW (ex. 80,000) or TL for trailer
Veh #3 VIN 17 digits
Veh #3 Value leave blank if no physical damage reqd
   
Please fax LOSS RUNS, COPY OF AUTHORITY, IRP MILES and FINANCIAL STATEMENTS to 859-342-8606 as soon as possible. These items are necessary to obtain a firm quote and must be submitted.

Thank you for submitting your insurance application. We will submit your information to several different companies so that we can get the best quote for your needs. If you have ANY questions, call 859-342-8600. We will contact you for additional information, if needed. Thanks for the opportunity to quote your fine operation.