TEC Insurance Portland Oregon Commercial Truck Insurance

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Please complete the application below to request your free, no-obligation insurance quote. Fields in RED are required.

1: Start Here

Select Your State:

2: Tell Us About Your Business

First Name:
Last Name:
Business or Corporate Name:
Years in Business:
Years Owned Commercial Equipment:
Years with Commercial Insurance:
DOT/MC#:
CA#:
OR File #:
Mailing Address:
City:
State & ZIP:
Phone:
Fax:
Email Address:
Garage Address:
Garage City:
Garage State & Zip:
Standard Radius of Operation:
Maximum Radius of Operation:
Annual Mileage:	(please provide 4 quarters IFTA mileage reports)

3: Auto Liability Limit

4: General Liability Limit (select one)

5: Commodities (Cargo) Transported
(include percentage and values of each)

Cargo	Avg. Value	Max Value	Commodity %
			%
			%
			%
			%
Cargo Limit:

6: List All Commercial Vehicles/Trailers

Year	Make	# Axles	Vehicle Type	GVW	Actual Cash Value $	Current Deductible $
1:
2:
3:
4:
5:
6:

7: List Driver(s) for Vehicles Referenced Above
(or provide copies of DMV reports)

Name	License #	DOB (mm/dd/yy)	# Accidents	# Violations	# Years CDL Experience	Hire Date
1:
2:
3:
4:
5:
6:

8: Prior Commercial Insurance Coverage

Effective From/To (mmyy/mmyy)	Carrier	Policy #	# Claims	Amount Paid
1:				$
2:				$
3:				$
4:				$
5:				$
6:				$

Brief description of claims:

9: Signature: Terms & Conditions

I hereby certify that all of the above information is true and complete to the best of my knowledge and I release the above information to TEC Insurance and TEC Equipment, Inc. for the processing of my request for an insurance policy quote.

Re-Enter Your Name:

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