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Genesee General

U.S. Liability Insurance

For Genesee Contracted Agents Only Residing in GA, Al, TN & SC. Forget Password?

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:

Atlanta	Boston	Charlotte
Cleveland	Denver	Detroit
Houston	Jacksonville	Kansas City
Los Angeles	Memphis	Miami
Mpls./St. Paul	New Orleans	New York City
Oklahoma City	Philadelphia	Pheonix
Portland	St.Louis	Salt Lake City
San Francisco	Tulsa	Baltimore Washington
Buffalo	Cincinnati	Dallas-Fort Worth
Hartford	Indianapolis	Little Rock
Louisville	Milwaukee	Nashville
Omaha	Pittsburgh	Richmond
San Diego	Seattle
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:

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