Owner Operator DIRECT - Leased Owner Operators

Owner Operators With Own Authority Quote

Welcome to the Owner Operator Direct program for Owner Operators With Your Own Authority! There are many factors that affect rates. Please provide all of the information requested below so that we may provide you with the lowest rate possible.

(* indicates required fields)

GENERAL INFORMATION
*First Name:
*Last Name:
*Street Address/Apt. No.:
P. O. Box:
*City:
*State:
*Zip:
E-mail address:
Cell phone:
Home phone:
Fax:
*How do you wish to be contacted with your quote?:
*How did you hear about us?:
*MC/DOT # :

DRIVER INFORMATION
*Date of birth:
*Number of years driving experience:
*Number of moving violations in the last three years:
*Number of accidents in the last three years:

TRACTOR INFORMATION
*Tractor model year:	*Tractor
*Tractor stated value:

TRAILER INFORMATION

*Trailer #1 model year:

*Trailer #1 trade name:

*Trailer #1 stated value:

(please include value of
tarps, chains & binders)

Trailer #2 model year:

Trailer #2 trade name:

Trailer #2 stated value:

(please include value of
tarps, chains & binders)

Trailer #3 model year:

Trailer #3 trade name:

Trailer #3 stated value:

(please include value of
tarps, chains & binders)

COVERAGES NEEDED
*Do you have a current policy?	Yes No
Please provide expiration date of your current policy:	mm dd yyyy
*Liability:
*Physical Damage Deductible:
*Cargo:
*Cargo Deductible:
*Commodity(s):

OPERATION INFORMATION

*Radius:

0-100	%
101-300	%
301-500	%
301-500	%
500+	%

(Must equal 100%)

*List three largest cities entered in your operation:

*1.
*2.
*3.

Loss History (last 3 years):

From-To

Insurance Company

Amount of Losses

From-To

Insurance Company

Amount of Losses

From-To

Insurance Company

Amount of Losses

ADDITIONAL INFORMATION

Is there any additional information you would like to provide
pertaining to your coverage?

** Higher limits available upon request.

We will promptly deliver your quote to you via the method you selected above.

The completion of the application for insurance creates no express or implied obligation on the part of Lancer to offer a quote or provide insurance as requested.

An "electronic signature" means an electronic sound, symbol, or process attached to or logically associated with a record executed or adopted by a person with intent to sign the record.

By clicking on the "Submit Now" button below, you are acknowledging your signature to this application for insurance.

Lancer Insurance Company and its insurance affiliates use information collected from consumer reporting agencies such as your driving record and claims history in order to offer you the most appropriate rate. Please review our Privacy Policy.

Thank you for choosing Owner Operator Direct.