AIBNET.COM | Trucking insurance, hauling insurance, cargo insurance, freight insurance and auto liability insurance.

Please complete the following information and a representative from AIB will contact you to answer your questions and give you a quote for the coverage you require.

If there are a few questions that you cannot answer or if there are questions that don't apply to you, type "n/a".

Please Enter Today's Date:

Years in Business:

When does your current insurance expire?

Your ICC Number:

Are you an owner/operator or do you own the company?

Are you an owner/operator interested in obtaining your own authority?:

Contact Information

Company Name:

Contact Last Name:

Contact First Name:

Company Address:

City, State and Zip:
,

Office Phone Number:

Home Phone Number:

Cell Phone Number:

Email Address:

Account Information

Size of Account:

Specific Commodities Hauled:

Maximum Radius:
Miles

Radius of Operations by Percentage:

	0 to 50 Miles	%
	51 to 200 Miles	%
	201 to 500 Miles	%
	501 to 750 Miles	%
	751+ Miles	%

Major Cities Traveled Through:

Loss History
(Please complete thoroughly and accurately):

Prior Insurance Carrier or Company	All Losses (Amounts & Coverage)
1999-2000	1999-2000
1998-1999	1998-1999
1997-1998	1997-1998
1996-1997	1996-1997

Coverages Needed
(Please Indicate Limits and Deductibles):

Primary Liability
(Check only if you have or you have applied for ICC#)

	Limits
	Deductible:

Cargo
(Check only if you have or you have applied for ICC#)

	Limits
	Deductible:

Physical Damage

	Limits
	Deductible:

General Liability

	Limits
	Deductible:

Non-Trucking Liability (for owner operators)

	Limits
	Deductible:

Other Coverages Needed