Contact

Drivers

Equipment

Operations

Coverage

Business & Contact Information

Basic details about the insured and the person you spoke with.

Telemarketer note: Fields marked * are required to generate a quote. Fill in as much as possible.

Business / Company Name

Primary Contact Name

Title / Role

Phone Number

Email Address *

Business Address

City

State

ZIP Code

Business Details

DOT Number

MC Number (if applicable)

Years in Business

Business Entity Type

Effective Date Needed

Telemarketer Name

Step 1 of 5

Driver Information

Add all drivers who will operate the insured vehicles. Include all listed drivers on the current policy.

Step 2 of 5

Vehicle & Equipment

Details for each truck or unit to be insured. Add all vehicles on the policy.

Step 3 of 5

Operations & Cargo

How and where the trucks are operated, and what they haul.

Primary Cargo Type

Secondary Cargo (if any)

Operation Radius

Estimated Annual Miles (per truck)

Geographic Operations

Primary States of Operation

Do trucks cross into Canada or Mexico?

No Canada only Mexico only Both

Parking & Operations

Overnight Parking Location

Owner-Operator or Leased to Carrier?

If leased — Carrier Name

ELD / Dash Cam Equipped?

Step 4 of 5

✓

Quote Request Submitted!

The details have been emailed to Merrill Insurance Agency and saved to HubSpot.
A follow-up task has been assigned to the agent.

Prospect:

Saving to HubSpot...