"*" indicates required fields

Thank you for your interest in receiving a quote from Jakob Insurance Brokerage Corporation. This form should only take about 5-10 minutes to complete. Don't worry if you don't have everything. You can always click the "Save and continue later" button below. We'll email you a private link to pick up where you left off.

When do you want your policy to start?*

MM slash DD slash YYYY

What kind of business do you operate?*

Which type of insurance are you looking for?*

Check all that apply.

General Liability

Business Owners Policy

Commercial Auto

Garage & Dealers Policy

Workers Comp

Trucking

Professional Liability

Equipment Floater - Inland Marine

Property

Commercial Umbrella

Cyber Liability

Other

Other type of insurance*

Primary Insured Name*

First Last

Insured Date of Birth*

Month

Day

Year

Email*

Work Phone

Mobile Phone*

Can we text you?*

Yes

Please visit our Privacy Policy regarding Texting/SMS communication.

How were you referred to us?

Business Information

Legal Business Name*

Entity Type*

DBA

FEIN

Website

Business Address*

Street Address City State Zipcode

Mailing Address*

Same as Business Address

Street Address City State Zipcode

Year Business Started*

Years operating this business?*

Years experience in this field?*

If less than 3 years experience, explain your prior experience and any Specialized Training or Certification*

Is this business affiliated with a franchise?

Yes

DOT#

MC#

Is there more than one owner of the business?*

Yes

Additional Business Owners

Additional Owners List

Owner Name	Email	Phone	Company Role	Actions

There are no Owners.

Maximum number of owners reached.

Vehicles

Are all vehicles garaged at the business address?*

Yes

Vehicles List

Year	Make	Model	VIN	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Trailers

If you have a trailer(s) you want listed on your policy, enter their information below.

Trailers List

Trailer Type	Year	Make	Model	Actions

There are no Trailers.

Maximum number of trailers reached.

Primary Insured Driver Info

Primary Insured: Drivers License Number*

Primary Insured: Drivers License State*

Commercial License? (CDL)

Yes

Year CDL Issued

Additional Drivers

Do any of your drivers take the vehicle(s) home at night?*

Yes

Have all drivers had a valid U.S. driver's license for at least 2 years?*

Yes

Drivers List

Driver Name	Date of Birth	Drivers License #	Drivers License State	Hire Date	Actions

There are no Drivers.

Maximum number of drivers reached.

Do you use contract or occasional drivers not listed above?*

Yes

How many drivers used annually?*

Trucking Underwriting

Projected annual mileage*

Number of Trailers to insure

What coverages are you looking to have in place?*

Check all that apply

Auto Liability

Physical Damage

Cargo

General Liability

Bobtail

Non-Trucking Liability

Umbrella / Excess

Commercial Property / Premises

Occupational Accident

Workers Comp

Hired / Non-Owned Auto

What are the minimum years of CDL experience required for drivers?

What are the maximum Daily and Weekly driving hours for each driver?

How are drivers paid?*

Hourly

By Trip

By Mile

Other

Which of the following is part of your driver screening/hiring process?*

Employment Background Check

Criminal Background Check

MVR Review

Behavioral / Integrity Test

Pre-Employment Drug Test

Road Test

Pre-Employment Screening Program (PSP) report for FMCSA

Check all that apply

In the past 5 years have you, or any driver, been convicted of any of the following?

Check all that apply

Leaving the scene of an accident / hit and run

Felony conviction involving a motor vehicle

Driving while license suspended or revoked

DUI or DWI

Negligent Homicide

Unlawful use of vehicle

Speed contest or racing

Reckless Driving

Speeding 20mph+ over the limit

Name, conviction, date, and details

Are drivers covered by workers comp?*

Yes

Do you haul for hire?*

Yes

Do you Barter Hire or Lease any drivers or vehicles out for others to use?*

Yes

Which party provides primary auto liability coverage?*

My Business

Other Party's Business

Do you Barter Hire or Lease any drivers or vehicles to haul under your authority?*

Yes

Are owner-operators subject to the same hiring, training, and equipment maintenance standards as company drivers?*

Yes

On what basis are vehicles and drivers leased?*

Permanent

Temporary / Trip Basis

Do you require and get evidence that leased vehicles owners purchase non-trucking liability?*

We will need a copy of the lease agreement

Yes

Does your company allow any of the following practices?

Check all that apply

Deadheading

Trailer Spotting

Double and/or Triple Trailer Hauling

Team Driving

Slip Seat / Relay Drivers

Non-Employee Passengers

All drivers to bring vehicles home

Trucking Underwriting

Do you need Federal Filings*

Yes

Note: For Federal Filings, an MCS 90 Endorsement is needed too.

Do you need State Filings?*

Yes

State(s) and Permit #s*

Is any part of your operation seasonal?

Yes

Does vehicle(s) have an ELD installed?

Yes

ELD Provider

What state(s) does your business operate in?

What are the 3 largest cities you enter?

Does your business provide any of the following general services?*

Storage

Loading / Unloading

Packing / Crating

Rigging

Decking / Tarping / Blanket Wrapping Freight

Delivery / Installation Services

Garaging

Vehicle and Equipment Repair

Commercial or Residential Moving Services

Does your business generate revenue from any services other than trucking for hire?*

Yes

Please explain other revenue generated*

Have you ever changed your operating name?*

Yes

Do you operate under any other names currently?*

Yes

Do you operate as a subsidiary of another company?*

Yes

Have you purchased, sold, or applied for authority over the past 3 years?*

Yes

Have you ever lost, or had authority withdrawn, or have been/are under probation by any regulatory authority? (FHWA, PUC, etc.)*

Yes

Do you agree to report all newly hired operators?*

Yes

Do you agree to report all newly purchased or leased equipment?*

Yes

Business Information Continued

What is your total annual sales/revenue? (Gross)*

Do you have employee(s)?*

Yes

Owner payroll*

Number of Full-time employees*

Estimated annual payroll*

Do you lease your employees?*

Yes

Number of Part-time employees*

Do you use any subcontractors? (1099s)*

Yes

Number of subcontractors*

Subcontractor annual payroll*

What type of work do your subs perform?*

Do you have a written contract with your subs requiring them to name your business as Additional Insured and show proof every year?*

Yes

Not yet

Trades Information

Construction of New Homes/Buildings

Remodeling / Renovation Work

Maintenance/Repair Work

Number of contractor licenses you currently hold*

Do operations include installation, service, or repair?*

Yes

Do business services include cleaning construction sites including debris removal?*

Yes

Do you perform snow and/or ice removal?*

Yes

Do you remove snow from streets or highways?*

Yes

Do operations involve the use of a crane?*

Yes

Do operations involve excavation?*

Yes

Select the types of excavation you perform

General excavation or trenching

Blasting

Dredging

Swimming pool excavation

Wrecking or demolition

Percentage of work involving excavation*

Do you use OSHA approved trenching/blasting safeguards?*

Yes

Do you demolish whole buildings or structures?*

Yes

Do jobs involve or expose employees to the following?

Select all that apply

Asbestos removal or exposure

Disaster recovery work

Fire, water, mold damage restoration or remediation

Lead paint removal

Oil, gas, or wells

Building and Property Information

My business location is*

Leased Property

Owned Property

Work From Home

Do you need property coverage for the building?*

Yes

Have you made any tenant improvements?*

Yes

In the future

How much tenant improvement coverage do you need?

Square footage of your business*

Do you have more than 1 business location?*

Yes

Building Information

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Other construction type*

Other roof type*

Has there been any updates to the roof, plumbing, or electrical?*

Yes

I don't know

Year Roof Updated?

Year Plumbing Updated?

Year Electrical Updated?

Additional Location(s)

Locations List

Location Address	Square Feet	Location is	Actions

There are no Locations.

Maximum number of locations reached.

Business Description

Please describe the nature of your business*

Please be descriptive as this will prevent additional underwriting questions and delays.

IT & Technology Information

Do you publish original works or content including software, media, gaming, etc.?*

Yes

Do you provide 3rd parties with any social network, search engine, gambling technology, financial technology, surveillance, white-hatting / ethical hacking, or infrastructure service (except telecommunications), or engage in any activity involving or similar to mining, trading, exchanging, storing, or offering any cryptocurrency, token, digital coin or equivalent?*

Yes

Do you distribute Unsolicited Advertising or Content?*

Yes

Does your business involve obscenity, adult content, or interactions with minors?*

Yes

Do you provide managed services or managed security services?*

Yes

Most recent fiscal year end Gross Revenue*

Most recent fiscal year end Total Expenses*

Revenue from largest contract*

Description of work from largest contract

Does a qualified attorney approve all your contracts, including existing and future contracts?*

Yes

In your contracts do you always cap your Liability?*

Yes

What is the liability cap?*

Do you require legal counsel to review if deviating from your standard terms?*

Yes

Do you have quality control program?*

Yes

Corporate Information

Have you gone through any merger, acquisition, sale of any assets, or other similar transaction within the past 24 months?*

Yes

Do you have any subsidiaries or foreign locations?*

Yes

Do you perform any of the following for third parties: online tracking, data aggregation, data mining, gaming or provide products or services that are specifically intended to enable others to engage in cryptocurrency mining, exchange, trading, initial offerings or storage?*

Yes

Customer Data

What type of customer data do you store?*

Do your products or any of your services perform the following security functions for third parties?*

Identification and Authentication

Intrusion Detection

Monitoring

Other Information Security

None of the above

Please indicate the primary customer industries that you serve*

Examples: healthcare, IT, government, aviation, etc.

Do you have custody of Personal Health Information (PHI) of third Parties?*

Yes

Are you responsible for collecting, storing, processing, safeguarding or any other activity involving the personal information of residents of foreign countries?*

Yes

Number of records you store, collect, process, or otherwise handle from third parties?*

Number of records of Non-public Personal Information (NPI) you collect, store, process, or otherwise handle?*

Which industry standards do you comply with?*

I don't know

PCI/DSS

NIST CSF

SOC 1/2

ISO 27001/2

ISO 8000/1

GDPR

HIPAA

FINRA

FDIC

HITECH

Other

None

Other industry standard*

Who manages you cybersecurity?*

Internal employee

External consultant

None

Do you encrypt all stored or accessed personal data?*

Yes

I don't know

How often do you backup your data*

Daily

Weekly

Monthly

Infrequently

None

I don't know

How long do you retain those backups?*

30 days or more

2 - 30 days

1 day or less

Do you use technical measures, devices or tools and techniques including: firewalls, anti-virus, passwords/authentication, to preclude unauthorized infiltration, modification or corruption of your network, including endpoints and sensitive assets within the network?*

Yes

I don't know

Do you require multi-factor authentication for remote access to your network?*

Yes

I don't know

Do you use any expired or unsupported operating systems or applications?*

Yes

I don't know

Is Remote Desktop Protocol disabled in your network?*

Yes

I don't know

Manufacturing

Is there any manufacturing, mixing, re-labeling, or repackaging of products?*

Yes

Please describe

Tools and Equipment

List tools/equipment and their value*

Human & Social Services Information

Does your business have a state license?*

Yes

State License #*

License Capacity*

Does your business provide child care?*

Yes

Childcare Information

Current maximum number of children you care for at one time*

Does the provider live in the home where the child care is provided?*

Yes

Does the provider provide 24-hour care or overnight care?*

Yes

Does the provider have any swimming facility besides an 18 inch deep plastic wading pool?*

Yes

Does the provider have someone to watch the children in an emergency that causes you to leave the daycare location?*

Yes

Does the provider accept borders in their home?*

Yes

Has the business' childcare license, certification, or registration ever been suspended or revoked?*

Yes

Has the business' childcare insurance ever been cancelled or non-renewed?*

Yes

Has the business had any claims against them in the last 5 years, or do they or their employees know of any incident that could result in a claim?*

Yes

Liability Limits (optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

Not sure, let's discuss

How much Business Personal Property coverage do you want?

Are you interested in Loss of Use / Business Income coverage?*

Yes

Not sure, let's discuss

Garage & Dealers Information

What types of vehicles you service, repair, or sell?*

Select all that apply

Private Passenger

Motorhomes

Motorcycles

Utility Trailers

Commercial Trucks

Commercial Trailers

Other

Other vehicles*

What is the total amount of coverage for other people's vehicles would you like?*

Example: If you have 20 vehicles at any one time and each vehicle has an average value of $25,000 then you would want $500,000 in coverage.

What parts and accessories do you sell over the counter?

None

New Parts

Used Parts

Exterior/Interior Trim

Apparel

Estimated annual over the counter sales

What are your security practices?*

3-Part Ticket

Key Cabinet

Protected Lot

None

Where do you store customer's vehicles?*

In Building

Fenced Area

Open Lot

Where do you store keys to customer's vehicles?*

Key Cabinet

In/On the Vehicle

Vehicle Mounted Lockbox

Taken Home

Other

Please describe Other key storage location*

If keys are stored in a vehicle mounted lockbox, are keys or lockboxes removed from the vehicles and stored inside after hours?*

Yes

Do you park customer vehicles on the street?*

Yes

Do you conduct towing operations?*

Yes

Are vehicles loaned to customers?*

Yes

Do you have a contract with customer, and get a copy of insurance, and a copy of drivers license?*

Yes

Do you ever store or display autos at a different location or lot other than where you conduct business?*

Yes

Please provide details of where and how often*

Is your business involved with any racing or exhibitions?*

Yes

Racing and Exhibitions Information

Do you have any owned vehicles used for racing or exhibitions?*

Yes

Is the vehicle titled in the name of the business?*

Yes

Do you service any vehicles involved in racing or exhibition events?*

Yes

Please describe work performed and location where work is performed*

Do you sponsor any racing related activities?*

Yes

Please describe sponsorship related activities*

Do you sell, install, or service racing tires?*

Yes

Garage & Dealers Information

List the percentage of the work you provide for each section below.

Where work is performed. Total must equal 100%.

Percent of work performed at Your Shop

% at Your Shop

Percent of work performed at Customer's Location

% at Customer's Location

Percent of work performed at Other

% Other

Please describe Other Location

Type(s) of work performed (in percent). Total must equal 100%.

Type of Work: Body/Paint

% Body/Paint

Type of Work: Brakes, Transmission or Suspension

% Brakes, Transmission or Suspension

Type of Work: Electrical

% Electrical

Type of Work: Mechanical

% Mechanical

Type of Work: Muffler/Radiator

% Muffler/Radiator

Type of Work: Oil Change

% Oil Change

Type of Work: Roadside Assistance

% Roadside Assistance

Type of Work: Safety Inspection

% Safety Inspection

Type of Work: Tires/Wheels

% Tires/Wheels

Type of Work: Tune Up

% Tune Up

Type of Work: Wash/Detail

% Wash/Detail

Type of Work: Welding

% Welding

Type of Work: Other

% Other (Upholstery, frame work, body work, window tint, windows, cleaning trailer, stereo system, etc.)

Please describe Welding type of work performed*

Please describe Other type of work performed*

Do you provide any off-site services or mobile services?*

Yes

What is the maximum miles away from your business that you offer your services?*

Dealer Sales Questions

% Vehicle Sales (Retail)

% Vehicle Sales (Wholesale)

% Vehicle Sales (Broker)

Number of Dealer Plates (Autos)

Number of Dealer Plates (Motorcycles)

Number of Dealer Plates (Boats)

Number of Dealer Plates (Trailers)

Number of Repairer/Transporter plates owned by you?

What states are you licensed in?

Number of vehicles sold annually*

Number held for sale (Average #)*

Number held for sale (Maximum #)*

Number of vehicles sold on internet auction

Number of vehicles sold on consignment

Do you sell "salvage titled" vehicles?*

Yes

Yes: How much structural repair done?*

Do you lease, rent or loan Dealer, Transporter, or any other type of plates?*

Yes

Do you lease or rent vehicles?*

Yes

Do you import or export vehicles?*

Yes

Do you operate an auction?*

Yes

Do you sell gasoline?*

Yes

Do you sell Liquefied Petroleum Gas (LPG)?*

Yes

If you paint, do you have a spray paint booth/separate room?*

Yes

Do you provide electric charging station for your customers?*

Yes

Do you sell tires?*

Yes

Do you service any tires?*

Yes

Additional Insured Information (optional)

Do you have anyone that needs to be listed as Additional Insured?

Yes

Additional Insured Information. (i.e. Name & Address)

You may upload your additional insured documents using the upload field below.

Additional Insured Document(s)

You may upload up to 10 PDF documents. If you have more documents you can send them to your agent after they contact you.

Drop files here or

Accepted file types: pdf, Max. file size: 12 MB, Max. files: 10.

Claims Information

Have you had any claims or losses in the last 5 years?*

Yes

What was the date, amount paid, and description of each loss or claim*

Has your business been cancelled or non-renewed in the last 4 years?*

Yes

Have you ever filed for bankruptcy?*

Yes

Bankruptcy: Please describe when and why*

Do you have ANY business insurance currently?*

Yes

Do you have ANY previous business insurance from the past 3 years?*

Yes

Current Insurance

Name of current insurance carrier?*

Expiration date of current policy*

MM slash DD slash YYYY

Current total insurance premium?

Current Policies

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 10.

Prior Insurance

Please enter your prior business insurance information below.

Prior Carrier Name 1

Policy Year 1

Premium 1

Prior Carrier Name 2

Policy Year 2

Premium 2

Prior Carrier Name 3

Policy Year 3

Premium 3

Additional Comments and/or Documents (optional)

Any additional comments

Any Additional Documents

Drop files here or

Accepted file types: pdf, Max. file size: 8 MB, Max. files: 5.

Wrapping Up

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

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

Yes

Would you like to create a user account to manage your submissions?*

Yes, create my account

Not at this time

Username*

Password*

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Phone

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