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Create a New Physical Damage Quote

Step 1 of 2
Information
We have recently added new underwriting questions and a new application to this physical damage program. If you have any questions on these changes please call Lindsey Albaugh.

Note: Quotes offered through this program are for comprehensive and collision physical damage per form NMA-1650.

Agency Information
Agent Name:
Note: This is the name of the agent requesting the quote, NOT the agency name.
Agency Name:
Agency Phone:  -  - 

Applicant Information
Applicant Name:
Select a state:
Number of years in business:
Number of years experience:
Number of Separate Claims/Losses in the last 3 years:
Does the applicant haul garbage, or operate tanker trailers/tanker trucks? No
Yes
Does the applicant haul logs, involved in logging operations, or haul any dump commodities? No
Yes
If the applicant doesn't currently have physical damage coverage, are any of the following statements true for the applicant?
  • Applicant's vehicle(s) are a new purchase
  • New lien or re-financing
  • Applicant had stopped business operations due to lack of work and is starting back up
No
Yes
Applicant has current physical damage coverage
Driver Information
Are all drivers between the ages of 23 - 70? No
Yes
Do all drivers have at least 2 years commercial driving
experience driving unit types to be listed on this quote?
No
Yes
Do all drivers hold a valid license for the type(s) of unit(s) operated? No
Yes
Does any driver have more than 5 minor violations? No
Yes
Does any driver have any major violations?
Major Violations:
  • DWI / DUI / OWI
  • Refusing a Substance Test
  • Reckless Driving
  • Manslaughter
  • Hit & Run
  • Eluding a Police Officer
  • Any Felony
  • Drag Racing
  • Driving while license is suspended
No
Yes
Does any driver have any more than 2 At Fault Accidents? No
Yes
Unit Information
Please enter the number of each unit per category:
Trucks
Tractors
Trailers
Non-Owned Trailers
(if option chosen tractors must be scheduled)
Private Passenger
Light Service Trucks & Vans
(no passengers for hire)
Dump Truck
(any vehicle with dump bed)
Other
Are any units used to carry passengers? No
Yes
Do any of the units ever haul one or more of the following?
  • Cement Mixers and/or Dump Trailers
  • Livestock (other than poultry)
  • Coal
  • Swinging Meats
  • Fireworks
  • Explosives
  • Radioactive Materials
  • Highly Flamable Materials
No
Yes
Are any units emergency vehicles, custom built, and /or fiberglass/glass lines tankers? No
Yes
Is there any unit used for personal use more than 20% of the time? No
Yes
Are all units that physical damage coverage is requested on owned by the named insured? No
Yes
Are any units that physical damage is requested on owned by an individual owner/operator who is not the named insured? No
Yes

 
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