1002 West Hwy 80 - P.O. Box 686
Pooler, GA 31322

Phone: 800-537-7152 Email: info@travisbarlow.biz Fax: 912-748-6084

We understand that towers have specialized insurance needs and that each tower has their own unique requirements. When you request an insurance quote, we ask for various and detailed information. This information is needed in order for us to provide tailored solutions and accurate quotes for your specific situation. Additionally, the information provided helps us to determine if you qualify for any rate reductions. Providing as much information as possible enables us to provide faster and better service. Your assistance in providing this information is appreciated.

 

Please let us know if you have any questions or comments.

 

 

 
Date
How did you hear about our Company?
 
 
Contact Name   Business Phone
Title   Cell Phone
Name of Business   Fax
Mailing Address   Other Phone
City   Email Address
State   Confirm Email Address
Zip    
 
 
Current Insurance Carrier    
Policy Expiration Date Legal Entity
Have you filed any claims in the past three years? Number of years
In Business in Current Name
Number of Claims Business is
Approx. amount paid for all claims $    
 
 

COVERAGES

 REGULATORY FILINGS
Docket/MC#
Auto Liability (CSL) ICC (Fed Hwy)
Uninsured/Underinsured Liability (BMC 91/91X)
Medical Payments Cargo (BMC 34)
Personal Injury Protection (FL only) MCS 90
General/Garage Liability City Filings
Garage Keepers Limits State Filings
Dealer / TransportTags  
 
 

OPERATIONS:

 
Does your business: percentage of your business?   percentage of your business?
Do Auto Repair
% Voluntary Repossession %
Do Auto Body work
%Involuntary Repossession %
Towing Only
%Sell Used Auto Parts %
Other (Explain Below)
%Sell Used or Recapped Tires %
Describe Other
 
 
Types of towing agreements: percentage of your business?   percentage of your business?
Motor Clubs % Dealerships %
General Public % Commercial %
Other (Describe below) % Police %
Describe Other
 

DRIVER INFORMATION

  Name Yrs Exp
Towing		 Date of Birth
In the past 3 yrs #
Drivers License No.
 Driver
State 		Full or Part
Time		 Yrs with
Company
Moving
Violations
Accidents
1
2
3
4
5
6
7
8
9
10

 

VEHICLE INFORMATION

  Year
Make
Model
Type
GVW
(lbs)
VIN Number
Original Cost New
Comp/CollIision

OnHook/Cargo

1
2
3
4
5
6
7
8
9
10

If you do not find your vehicles make, model or type listed please include that information in the box below marked other information and comments

Other Information or Comments



This web site may not be used to bind or issue insurance. You may not endorse, alter or amend vehicles or insurance coverage here. You may not make any changes to your insurance policy on this web site. This web site was designed for communication and insurance quoting purposes ONLY. Products and service may not be available in all geographical areas and we do not write in any state in which we are restricted by licensing requirements. Please see our disclaimer page for full details.

CA# OD25393