Cooper Insurance & Associates

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	What changes are made to your policy once the regulatory filings for your authority are issued?

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have questions
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contact us!

Forms

Get a Quote
Certificate of Insurance Request
Report a Claim
Driver Request Form
Request Information

Please fill out the information below to receive your free quote!

*Signifies a required field below

DATE:

*APPLICANT:

(Individual Name/Owner)

* EMAIL ADDRESS

* PHONE #:

CELL #:

D/B/A:

GARAGE ADDRESS:

Street:	City:	State:	Zip:

(Where you park your trucks)

*COVERAGE NEEDED:

Primary Coverage	Liability
	Physical Damage
	Cargo
OR
Non-Trucking(Bobtail) and Physical Damage

LIABILITY LIMITS:

Amount:

Other:

ICC/FHWA Filings:

MC#:
DOT#:
GA MCA#:

OTHER COVERAGES:

Hired Auto:
Non-Owned Trailer:
General Liability:

RADIUS:

(Furthest Destination)

STATES TRAVELED:

CITIES TRAVELED:

CARGO LIMIT:

Amount:	Other:	(Keep in mind that most shippers will require a $100,000 limit)

COMMODITIES:

#1:

#2:

#3:

#4:

Commodities:	%:	Value of Avg. Load:	Max value of Load:




(Example: Lumber	45%	$30,000	$50,000

YEARS IN BUSINESS:

EXPIRATION DATE:

PRIOR CARRIER INFO:

1st Year:

2nd Year:

3rd Year:

Dates:	Insurance Co:	Claims/Losses:	Amount Paid:



3 YR HISTORY (if you did not have insurance in your name, please indicate companies that you were leased on, or companies for which you were a driver)

VEHICLE SCHEDULE:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10

Year:	Make/Model:	Radius:	GVW:	Value:	Deductible:

DRIVER INFO:

#1:

#2:

#3:

#4:

#5:

#6:

#7:

#8:

#9:

#10:

Name:	DOB:	Yrs w/ CDL:	Date of Hire:	Violations:










(Try to be as specific as possible when reporting violations! Give dates, and if speeding, give how much over posted limit. We need prior three year history.)

HOW DID YOU FIND US?

COMMENTS:

810 Rock Quarry Road, Stockbridge, GA 30281 (770)389-0089