"*" indicates required fields

Thank you for your interest in receiving a quote from Bierwirth Insurance Agency. 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 the policy, or policies, to start?*

MM slash DD slash YYYY

Which type of insurance are you looking for?*

Check all that apply.

Trucking

Garage & Dealers Policy

General Liability

Professional Liability (E&O)

Workers Comp

Property (Building coverage, contents, etc.)

Commercial Auto

Cyber Liability

Equipment Floater (Tools coverage, etc.)

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*

DBA

Entity Type*

FEIN

Website

Business Address*

Street Address City State Zipcode

Mailing Address*

Same as Business Address

Street Address City State Zipcode

Year Business Started*

Years of experience operating this business?*

Years of experience in this field?*

Is this business affiliated with a franchise?

Yes

DOT#

MC#

Number of Owners

Additional Business Owners

Owner 2

2. Owner Name*

First Last

2. Owner Date of Birth*

Month

Day

Year

2. Owner Phone

2. Owner Email

2. Owner Role

Owner 3

3. Owner Name*

First Last

3. Owner Date of Birth*

Month

Day

Year

3. Owner Phone

3. Owner Email

3. Owner Role

Owner 4

4. Owner Name*

First Last

4. Owner Date of Birth*

Month

Day

Year

4. Owner Phone

4. Owner Email

4. Owner Role

Vehicles

Number of Vehicles*

Are all vehicles garaged at the business address?*

Yes

Are all vehicles titled in the name of the business?*

Yes

Vehicle 1

1. Year*

1. Make*

1. Model*

1. VIN*

1. Gross Vehicle Weight

1. Radius of Travel

1. Garaging Zip*

1. Collision Deductible

1. Comprehensive Deductible

1. Does this vehicle have permanently attached equipment?

Yes

1. Value of attached equipment

Vehicle 2

2. Year*

2. Make*

2. Model*

2. VIN*

2. Gross Vehicle Weight

2. Radius of Travel

2. Garaging Zip*

2. Collision Deductible

2. Comprehensive Deductible

2. Does this vehicle have permanently attached equipment?

Yes

2. Value of attached equipment

Vehicle 3

3. Year*

3. Make*

3. Model*

3. VIN*

3. Gross Vehicle Weight

3. Radius of Travel

3. Garaging Zip*

3. Collision Deductible

3. Comprehensive Deductible

3. Does this vehicle have permanently attached equipment?

Yes

3. Value of attached equipment

Vehicle 4

4. Year*

4. Make*

4. Model*

4. VIN*

4. Gross Vehicle Weight

4. Radius of Travel

4. Garazing Zip*

4. Collision Deductible

4. Comprehensive Deductible

4. Does this vehicle have permanently attached equipment?

Yes

4. Value of attached equipment

Vehicle 5

5. Year*

5. Make*

5. Model*

5. VIN*

5. Gross Vehicle Weight

5. Radius of Travel

5. Garaging Zip*

5. Collision Deductible

5. Comprehensive Deductible

5. Does this vehicle have permanently attached equipment?

Yes

5. Value of attached equipment

Vehicle 6

6. Year*

6. Make*

6. Model*

6. VIN*

6. Gross Vehicle Weight

6. Radius of Travel

6. Garaging Zip*

6. Collision Deductible

6. Comprehensive Deductible

6. Does this vehicle have permanently attached equipment?

Yes

6. Value of attached equipment

Drivers

Primary Insured: Drivers License Number*

Primary Insured: Drivers License State*

Commercial License? (CDL)

Yes

Year CDL Issued

Number of Additional Drivers*

Let's add 8 of your drivers now. We will contact you to get your additional drivers information.

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

Yes

Driver 1

1. Name*

First Last

1. Date of Birth*

Month

Day

Year

1. Drivers License #*

1. Drivers License State*

1. Commercial License? (CDL)

Yes

1. Year CDL Issued

1. Hire Date

Month

Day

Year

Driver 2

2. Name*

First Last

2. Date of Birth*

Month

Day

Year

2. Drivers License #*

2. Drivers License State*

2. Commercial License? (CDL)

Yes

2. Year CDL Issued

2. Hire Date

Month

Day

Year

Driver 3

3. Name*

First Last

3. Date of Birth*

Month

Day

Year

3. Drivers License #*

3. Drivers License State*

3. Commercial License? (CDL)

Yes

3. Year CDL Issued

3. Hire Date

Month

Day

Year

Driver 4

4. Name*

First Last

4. Date of Birth*

Month

Day

Year

4. Drivers License #*

4. Drivers License State*

4. Commercial License? (CDL)

Yes

4. Year CDL Issued

4. Hire Date

Month

Day

Year

Driver 5

5. Name*

First Last

5. Date of Birth*

Month

Day

Year

5. Drivers License #*

5. Drivers License State*

5. Commercial License? (CDL)

Yes

5. Year CDL Issued

5. Hire Date

Month

Day

Year

Driver 6

6. Name*

First Last

6. Date of Birth*

Month

Day

Year

6. Drivers License #*

6. Drivers License State*

6. Commercial License? (CDL)

Yes

6. Year CDL Issued

6. Hire Date

Month

Day

Year

Driver 7

7. Name*

First Last

7. Date of Birth*

Month

Day

Year

7. Drivers License #*

7. Drivers License State*

7. Commercial License? (CDL)

Yes

7. Year CDL Issued

7. Hire Date

Month

Day

Year

Driver 8

8. Name*

First Last

8. Date of Birth*

Month

Day

Year

8. Drivers License #*

8. Drivers License State*

8. Commercial License? (CDL)

Yes

8. Year CDL Issued

8. Hire Date

Month

Day

Year

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

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 employees*

Estimated annual payroll*

Do you lease your employees?*

Yes

Describe the type of work your employees perform?*

Do you use any subcontractors? (1099s)*

Yes

Insured Subcontractors Annual Payroll*

% Subs Work Residential*

If none, enter 0.

% Subs Work Commercial*

If none, enter 0.

What type of work do your subs perform?*

Do you have a written contract with your subs that contains a Hold Harmless agreement?*

Yes

Not yet

Do you require your subs to give you Certificates of Insurance covering the entirety of your policy period, naming you as Additional Insured?*

Yes

Not yet

Building and Property Information

My business location is*

Leased Property

Owned Property

Work From Home

Do you need 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)

Location 2 is*

Owned

Leased

Location 2: Address*

Street Address Address Line 2 City State ZIP Code

Location 2: Square Feet

Add 3rd Location

Yes

Location 3 is*

Owned

Leased

Location 3: Address*

Street Address Address Line 2 City State ZIP Code

Location 3: Square Feet

Business Description

Please describe the nature of your business*

Customer Data

What type of customer data do you store?*

Do you store date from third parties?*

What security policies do you use?*

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

Manufacturing

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

Yes

Please describe

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*

Current Insurance

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

Name of current insurance carrier?*

Expiration date of current policy*

Month

Day

Year

Why are you looking for a new quote?

Current total insurance premium?

Current Policies

Drop files here or

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

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

Other

Please describe Other key storage location*

Do you tow for hire?*

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

How many Dealer Plates do you have?*

Number of Repairer/Transporter plates owned by you?

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?*

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.

Additional Comments and/or Current Policy Upload (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

What is the best time to call and discuss your quote?*

Morning

Afternoon

Evening

Anytime

Other

Please specify the best time to call*

Would you like a quote from a specific agent?

Consent*

By clicking Select and Agree below, I am providing my ESIGN signature and express written consent agreement to permit Bierwirth Insurance Agency and parties on their behalf, to contact me at the number/s provided below, to continue to service my account, as well as bring to my attention new product policies and competitive rates via the use of phone calls, SMS/MMS messages and email.

I Agree

Signature

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*

Enter Password Confirm Password

Name

This field is for validation purposes and should be left unchanged.

Bierwirth Insurance Agency

Links

Connect with us

Business Insurance Quote

Business Information

Additional Business Owners

Owner 2

Owner 3

Owner 4

Vehicles

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Drivers

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Driver 7

Driver 8

Underwriting

Underwriting

Business Information Continued

Building and Property Information

Building Information

Additional Location(s)

Business Description

Customer Data

Manufacturing

Claims Information

Current Insurance

Liability Limits (Optional)

Garage & Dealers Information

Garage & Dealers Information

Dealer Sales Questions

Additional Insured Information (Optional)

Additional Comments and/or Current Policy Upload (Optional)

Wrapping Up

Texas Office

Get Insurance

Resources

For Clients

Start Your Quotes

Select an Insurance Type

All Business Insurance

Family & Individual Insurance

General Contractors

Trade Contractors

Course of Construction

Commercial Auto Insurance

Login

Don’t have an account?

All Business

Insurance

Family & Individual

Insurance

General

Contractors

Trade

Contractors

Course of

Construction

Commercial

Auto Insurance