Name: Burnside Insurance Group
Price range: $$

Phone

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Business Owner's Name*

First Last

Contact (Email)*

Contact (Phone)*

SMS Consent

By checking this box, you consent to receive text messages from Burnside Insurance Group at the mobile number provided regarding your insurance inquiries, quotes, and policy updates. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Effective Date for Policy

Business Information

Legal Business Name*

Mailing Address*

Street Address City State ZIP Code

Garaging Address*

Same as Mailing Address

Shipping Address*

Same as Mailing Address

Years in Business*

DOT Number*

FEIN

Federal Filings

Y

N

State Filings

Y

N

Previous Insurance Cancelled or Non-Renewed

Y

N

Radius of Operations

Total percent of all 4 radius options below must add up to 100%.

Percent 0-50 Miles*

Percent 51-200 Miles*

Percent 201-500 Miles*

Percent 500+ Miles*

Percent Total Radius

Truck(s) Information

Total Number of Trucks*

Vehicles List*

VIN

Year

Make

Model

Value

Class Key

Deductible

Ownership

Total Value of Trucks

Class Keys & Body Types

Class 8, 33,001 pounds+ - Box Truck, Straight Truck, Flatbed Truck, Stake Truck, Tractor, Dump Truck
Class 7, 26,001-33,000 pounds - Box Truck, Straight Truck, Flatbed Truck, Stake Truck
Class 6, 19,501-26,000 pounds - Box Truck, Straight Truck, Flatbed Truck, Stake Truck
Class 5, 16,001-19,500 pounds - Pick Up, Box Truck, Straight Truck
Class 4, 14,001-16,000 pounds - Pick Up, Box Truck, Straight Truck
Class 3, 10,001-14,000 pounds - Pick Up, Box Truck
Class 2b, 8,501-10,000 pounds - Pick Up
Class 2a, 6,001-8,500 pounds - Pick Up

Trailer Information

Total Number of Trailers*

Trailers List

VIN

Year

Make

Model

Value

Body Type Key

Total Value of Trailers

Driver Information

Please make sure to include yourself if you are a driver.

Drivers List

If you are a driver, remember include yourself. Date of Birth format must be MM/DD/YYYY.

First Name

Last Name

License Number

License State

Date of Birth

# Yrs Driving/CDL Exp.

Commodities

Combined percent of all commodities must equal 100. This is a large list below. Leave any commodities blank that you do NOT haul.

Agricultural Equipment

Alcoholic Beverages

Appliances

Arms, Ammunition, Fireworks

Automobile Parts and Accessories

Automobiles (5 or Less)

Automobiles (6 or More)

Beverages

Building Materials

Canned Goods

Cannabis and CBD

Cement, Sand, or Gravel

Coal

Cranes

Dangerous Articles, Explosives, Corrosives, Flammables

Documents

Eggs

Frozen or Refrigerated Products

Fracking

General Merchandise

Intermodal Containers

Jewelry

Grain, Hay, Feed

Hanging Meat

Liquid Haulers

Livestock and Live Poultry

Logs

Lumber

Light Machinery

Machinery and Heavy Equipment

Meat

Metal and Steel

Mobile Homes

Tobacco

Pipe, Cable, and Wire

Nursery Plants, Trees, Flowers

Office Equipment

Paper and Paper Products

Produce

Recreational Vehicles, Boats, RVs

Refuse Garbage

TV, Radios and Electronics

Scrap Metal

Seafood

Total Percent of Commodities

Error: Commodities total More Than 100%. Please adjust your chosen commodities above.

Additional Comments

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How were you referred to us?

All the above information is accurate and true to the best of my knowledge.*

Yes

Get Your US DOT Number & CA # Motor Carrier Fast!

No matter what type of trucks you own, we’ve got you covered

18 Wheelers

Big Rigs

Box Trucks

Car Haulers

Cement Trucks

Commercial Fleets

Dry Vans

Dump Trucks

Flat Beds

Food Trucks

Freight

Garbage Trucks

Gooseneck Trailers

Hopper Trailers

Household Movers

Limousines

Logging Trucks

Mobile Home Movers

Reefer Trailers

Semi Trucks

Tow Trucks

Waste Haulers