WTIS Quote Form

Address: 11950 Aviation Blvd. Inglewood, CA 90304 Toll-Free: 1-800-937-8785
MKTG: [?] HOW DID YOU HEAR ABOUT US?	Individual:
CUST CODE:
DATE:	Feb - 05 - 2012
AGENT:

PHONE#: [?] Please list all available phone numbers so we may easily be in contact with you
PHONE2 #:
FAX#:
MOBILE#:
EMAIL: [?] Enter email address here or "NONE"
TYPE OF BUSINESS:
YRS BUSINESS:	Online [?] Do you want Online Access to your Insurance data through the Internet?

TYPE OF CARRIER:		State:
INSURED NAME:
BUSINESS NAME:
ADDRESS: [?] Enter complete mailing address here and garaging location below.
GARAGING:
TYPE OF CARGO: [?] Please be specific on types of cargo carried along with percentage of each. Use the Notes section at the bottom if more space is needed.

FEIN/SSN:
* GROSS RECEIPTS: $
PAYROLL: $
# OF EMPLOYEES:
OWNERS NAME:
WHAT KIND OF WORK:
MILEAGE:

FILING NEEDED: [?]

DMV#:

MC#:

STATE#:

SUBHAULERS:

YES NO

PRIOR EMPLOYMENT [?]

RADIUS: [?]

CITIES:

CURRENT INSURANCE: [?] WHO IS YOUR CURRENT INSURANCE CO ? WHEN DOES THAT POLICY EXPIRE?		EXP. DATE	- -	CLAIMS/PAID:
PREVIOUS INSURANCE:		EXP. DATE	- -	CLAIMS/PAID:

DRIVER SCHEDULE:			DRIVERS
NAME (OWNER) [?] GET ALL DRIVERS WHO PLAN TO OPERATE EQUIPMENT. MAKE SURE YOU ASK FOR THEIR NAME AS SHOWN ON THE DRIVERS LICENSE. GET THE OWNERS DRIVERS INFORMATION EVEN IF HE DOES NOT INTEND TO DRIVER AND NOTE "NOT A DRIVER" NEXT TO HIS NAME. ALSO ASK THE FOLLOWING: "WITHIN THE LAST 3 YEARS HAVE YOU HAD ANY ACCIDENTS? HOW MANY TICKETS HAVE YOU RECEIVED IN THE LAST 3 YEARS" NOTE THAT INFO NEXT TO THE NAME Make sure name is exactly as shown on drivers license. Please list accidents and/or citations within last 3 years in notes field by each driver. (ie: 1 Acc & 1 speed).	DL#	DOB Month / Day / Year	EXP [?] How long has the driver been licensed for, and operating, the type of equipment shown here ? YEARS	NOTES
		/ /
		/ /
		/ /

VEHICLE SCHEDULE:						[?] ASK THE CLIENT HOW MUCH HIS TRUCK IS WORTH TODAY.
YEAR [?] LIST SPECIFIC INFORMATION ABOUT THE EQUIPMENT TO BE INSURED. ALL TRACTORS MUST HAVE A CORRESPONDING TRAILER. IF NO OWNED TRAILER THEN ENTER NON-OWNED. LIST A VERY CLEAR DESCRIPTION OF THE TRUCK BODY. Use Other section to help us better understand your truck configuration.	MAKE	VIN#	BODY	OTHER	GVW(K)	VALUE ($)

COVERAGES: [?]

AUTO LIAB:		GEN LIAB:		CARGO: [?] What limit of cargo coverage will you need ? If Reefer Breakdown is required please advise in the Notes section below. Please note certain restrictions and/or limitations may apply to various target goods you might carry. Be sure to discuss this with the agent before purchasing cargo insurance.		PROP:
WORK COMP: [?] Do you currently have workers compensation coverage in force? Please advise # of employees and estimated payroll in the Notes section below.		NOTES: