Genesee General Genesee General of Colorado Gensee Special Brokerage GenPay Premium Finance Contact Us

On Line Quote Request-Auto

Please fill out the information below to receive your quote!
One of our underwriters will contact you within the next 24 hours.
Note: For 1 - 4 unit accounts only; for GA, AL, TN & SC states only.
(*) Signifies a required field below.
Producer  
DATE:
*AGENCY NAME:
*PHONE #:
FAX #:
*EMAIL:
CONTACT NAME:
Insured  
*NAME:
ADDRESS:
Street:
 
City: State: Zip:
*YEARS IN BUS:
*EFF. DATE: (mm/dd/yyyy)
*BUS DESC:
Route To  
UNDERWRITER:
Vehicles  
SCHEDULE:
#1:
#2:
#3:
#4:
*Year: *Make: VIN: GVW: ACV: *Body Type:
*RADIUS: (Furthest Destination)
LARGEST CITIES ENTERED:
AtlantaBostonCharlotte
ClevelandDenverDetroit
HoustonJacksonvilleKansas City
Los AngelesMemphisMiami
Mpls./St. PaulNew OrleansNew York City
Oklahoma CityPhiladelphiaPheonix
PortlandSt.LouisSalt Lake City
San FranciscoTulsaBaltimore Washington
BuffaloCincinnatiDallas-Fort Worth
HartfordIndianapolisLittle Rock
LouisvilleMilwaukeeNashville
OmahaPittsburghRichmond
San DiegoSeattle
For cities not shown above use the text fields below.
City #1: City #2: City #3:
 
*COMMODITIES:
#1:
#2:
#3:
Commodities: %: Value of Load: Max value of Load:
Example: Lumber 45% $30,000 $50,000
LEASED TO:
ADDRESS:
Street:
 
City: State: Zip:
  *Hauling for hire? Is insured hauling for more than one entity?
Driver Information
DRIVER INFO:
#1:
#2:
#3:
#4:
#5:
#6:
#7:
#8:
#9:
#10:
*Name: *DOB: CDL#: *Experience: Hire Date: *MVR Info:
(Try to be as specific as possible when reporting violations! Give dates, and if speeding, give how much over posted limit. We need prior three year history.)
Coverages  
 
Liab CSL: U/M:
Comp Ded: Coll Ded:
Cargo Lmt: Reefer Brkdn:
Non Trucking: Other:
MC#: USDOT#:
Excess Liab: Med Pay:
SCOL ded: Excess Cargo:
Cargo Ded:    
GL CSL:    
TxDOT#:    
3-Year Prior Carrier & Loss History (mm/dd/yyyy)
*CARRIERS:
1st Year:
2nd Year:
3rd Year:

Dates: Carrier: Claims/Losses: Amount Paid:
Comments  
COMMENTS: