Commercial Auto Insurance Survey
		Complete the following survey and a ProLogi.com representative will contact you within one working day.
Company Information
Company Name
Associate
Title
Address
Address 2
City, State, Zip
Telephone
Facsimile Number
eMail Address
Principal Officer or Owner
Insurance Contact
Insurance Contact Phone
Insurance Contact Facsimile
Fleet Information
Select your Category of Fleet		Trucker for Hire Private Carrier
Range of Transport		Interstate Intrastate
Number of Tractors
Number of Heavy Trucks
Number of Light Trucks
Number of Trailers
Number of Private Passenger
Is all the equipment operated owned by you?		yes no
Is all equipment owned scheduled?		yes no
Type of Carriage		Hazardous Non-Hazardous
Broadened Pollution Endorsement Required?		yes no
FHWA MC Number
DOT Number
PUC Number
State
Property Broker
Freight Forwarder
Commodities Transported
Commodity
		Percent Maximum Value
Commodity
		Percent Maximum Value
Commodity
		Percent Maximum Value
Insurance Carrier
Current Insurance Carrier
Policy Number		Exp. Date
Policy Limits
Policy Deductibles		BI PD
Physical Damage
Gross Miles
Is trailer interchange required?		yes no
Intermodal Agreement required?		yes no
Has insurance been cancelled or non-renewed in the past three years?		yes no
Total Fleet Value
Total Tractor Value
Total Trailer Value
Drivers Hired or Leased Last Year
Number Replaced
Company Drivers
Leased Drivers
Number Increased
Company Drivers
Leased Drivers