Non Emergency Medical Transportation NEMT Insurance Quote

Our online commercial auto form for NEMT providers will get the answers the insurance companies want to know as quickly as possible.

Step 1 of 2

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• Business Name
• Business Owners
  

  First Name	Last Name	Date of Birth	Phone

• Business Phone
• Business Begin Date
• Email
  
• Number of VehiclesPlease enter a number greater than or equal to 1.
• DOT Number (if any)
• Business Address
  
  Street Address
  
  Address Line 2
  
  City
  AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
  State
  
  ZIP Code
  
• Vehicles
  

  Year	Make	Model	Value	VIN	Date Purchased	Wheelchair Lift (Y/N)	Specialized disabled persons equipment	Used as a Taxi	Taxi box/meter installed	Used as an emergency ambulance	Owned by or contracted exclusively with a government entity

• Drivers
  

  First Name	Last Name	DL State	DL Number	Date of Birth	Social Security Number	If CDL – Date obtained

• Radius of Operation0-50 Miles51-100 Miles101-200 Miles201+ MilesI don’t knowHow far away from your location do you go (one way)? If different vehicles travel different lengths, please let us know also.
• Travel Out of State?Yes – We cross state linesNo – We stay within our state
• Date You Would Like To Begin Insurance Coverage
  
  Date Format: MM slash DD slash YYYY
  
• Currently Have InsuranceYes – I have CoverageNo – I’m Looking To Begin Coverage
• Current Insurance Coverages*
  

  Insurance Carrier Name	Type of Coverage	Policy Number	Expiration Date

• Driver Hiring Process
  
  • 
    Select All
  • 
    Employment background check
  • 
    MVR Check
  • 
    Road Test
  • 
    Criminal Background Check
  • 
    Pre-employment Drug Test

  Please check all appropriate boxes that apply to your business regarding the drivers you hire. Skip if no drivers are hired.

• Has Your Insurance Been Canceled In The Last Three Years?
  
  • Yes
  • No
• Have you filed bankruptcy within the last 10 years?*YesNo
• Is the applicant a for-profit transportation business or generating revenue through the use of the vehicle?YesNoAre you a for-profit, or a non-profit organization?
• Do you allow drivers to wait at airports, hotels, or other sites to solicit unscheduled passengers?YesNo
• Do any vehicles have rates posted inside the vehicle or charge metered rates?YesNo
• Do any vehicles display advertising, wording, or a phone number on the exterior?YesNo
• Do you hire, rent, or borrow autos from others without drivers to use in your business?YesNo
• Do you make arrangements for other public auto companies to provide transportation for your overflow business?YesNo
• Do you lease, rent, or loan vehicles to others without drivers?YesNo
• Notes and Comments<br />