Quote Forms:
 
Keuler Insurance Agency, Inc.    Mineral Point, Wisconsin.
Truck Insurance Quote
We work with several companies on commercial truck insurance.
Please complete the questions sbelow, and I will get back to you as soon as possible.

Contact Information:  (Items marked * are required)
Contact Name  * (you will need to provide your social security number or federal identification number to us when we call)

E-mail  *
Address
City
State
Zip
Phone  *

Present or Prior Insurance
Present Insurance Company Name
Policy Number With Present Company
# of Years With Commercial Coverage
Losses

Cities You Operate In, Or Deliver To

Coverages
Primary Liability
Non-trucking Liability
Filings
 Need Info!!
MC- Need Info!!
USDOT- Need Info!!
Single state filing Need Info!!

Units
 
Year
Make
Model
Identification#
Value
Radius
1.
2.
3.

Drivers
 
Name
Birth Date
Driver's License #
Years Experience
Date of Hire
1.
2.
3.

Cargo Limit - Limit Required
 
Types of Cargo
Percentage
Maximum Value
Average Value
1.
2.
3.

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.


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Keuler Insurance Agency, Inc.
222 High St.
Mineral Point, WI 53565
Office: 608-987-2832
Fax: 608-987-3023
Toll Free: 888-987-2021
e-mail: kkeuler@keulerinsurance.com

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