Trucking Quote Please fill the form below. * is a required field. * HAVE YOU ALREADY SPOKEN WITH ONE OF OUR AGENTS? IF, SO, WE WANT TO MAKE SURE THEY RECEIVE YOUR QUOTE SUBMISSION: No, I have not yet spoken with an Agent from The Buckner Company Yes, I spoke with Stacy Atkinson Yes, I spoke with Scott Cowan Yes, I spoke with JD Rex Yes, I spoke with Matt Vierig Yes, I spoke with Jason Wiggins Yes, I spoke with Dave Wittwer CONTACT INFORMATION Salutation: Mr. Miss. Mrs. Other First Name: Last Name: Title: Company: Federal Employer Identification Number (FEIN): Department of Transportation Number (DOT #): Website: * Email: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Misourri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: Fax: MC#: Years in Business: Description of Materials Hauled: POLICY INFORMATION: Date of Policy Inception: Limits of Liability—Primary: Limits of Liability—UM/UIM: PIP/Medical: Basic Limit Increased Limit Other Limits of Liability—GL: Yes No Limits of Liability—Cargo Limit: Hired Auto Required?: Yes No Has your transportation insurance policy been cancelled or non-renewed in the last five years?: Yes No Comp Deductible: Collision Deductible: Paragraph: (Include year, make, model, VIN and value of each vehicle/trailer you’d like to quote) Driver List: (Include First Name, Last Name, Date of Birth, State of License, License Number, and Date of Hire) Provide Class B/Fuel Tax Report (IFTA): (State Mileage for 2008, Mileage for 2009, Mileage for 2010) Projected Mileage for upcoming policy period: How Did You Hear About Us?: Search Engine Word of Mouth Our Agent Contacted You Trucking Magazine or Publication Trucking Tradeshow Magazine or Newspaper Article Other Interested in receiving a quote for Workers' Compensation? Yes No OTHER INFORMATION THAT WILL HELP US GET YOU THE BEST QUOTE: Loss Runs. Please email currently valued loss runs for the past four years, if possible, to jrex@buckner.com or fax to 801-365-0868.