Raymond Nelson Insurance Agency Inc.


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Request a Free Quote

We take pride in our unique approach to provide you with the best coverage to fit your needs. Customer service and competitive rates are our specialty. If your company has 20 power units or less, feel free to complete the form below to receive your no obligation quote or call us toll free at 1-800-343-6584.

If you operate more than 20 power units, please call us toll free at
1-800-343-6584 to request a proposal.

Start saving on your insurance today!

General Information

Company Name

Type of Business

Social Security/Tax ID #

MC or DOT Number

(If you have your own authority)

Contact Person

Company Address

City

State (call for information on states not listed)

ZIP/Postal Code

Phone Number

Fax Number

Preferred method of contact.

Phone Email Fax

Post Mail

Insurance Information

I haul under my own authority or need my own primary liability

I am an Owner/Operator and haul under someone else's authority

I do not have Federal Authority and only need State Filings

Account Size (power units)

Current Insurance Expiration Date

Specific Commodities Hauled

Major Cities Traveled Through

Limits of Liability Needed

Cargo Limits Needed

Physical Damage Coverage Required

Years in Trucking

Years with own Insurance

Radius Traveled

0-300 Miles

300-1000 Miles

Over 1000 Miles

Current auto liability insurance company (if applicable)

Auto liability company for previous year (if applicable)

Any accidents or losses in the past three years?

If you answered "Yes" to the above question, please describe in detail

Please provide any additional information about your company that may be helpful.

Driver Information

Name	Driver License #	DL State	Age	Years Exp.	Date Hired

Equipment Information (List all trucks, tractors and trailers)

Year	Make	Model	VIN	Value

If you have more drivers or equipment than this form allows, please call our office at 1-800-343-6584 for assistance.