Get A Quote

Fleets currently operating 5 or more vehicles please call 800-220-8294 to speak with an agent. Owner-operators and fleets under 5 vehicles please complete the below motor vehicle authorization form and submit to obtain a quote.

Quote Request Form

By completing and submitting this form I request that TRX Insurance Services, Inc. obtain my motor vehicle driving records and I grant permission for TRX to share the records and information contained in the records with the person or company with whom:

I am employed; or
I am Applying for employment; or
I am an independent contractor; or
I am applying for a position as an independent contractor

Also, by completing and submitting this form I grant TRX permission to share the records and the information contained in the records with any and all person or companies that may have an interest in my insurability as a driver including, for example, insurance companies and insurance brokers.

Also, by completing and submitting this form I agree that TRX shall not be responsible for any actions taken by anyone as a result of the use of information contained within my motor vehicle records. I release TRX and will hold TRX, its employees and representatives, free of any liability arising from TRX obtaining and/or providing this information for these purposes. Also, I grant TRX continued permission for all of the above until such time as I notify TRX in writing by certified mail return receipt request that the permission is withdrawn.

* First Name:	* Last Name:
*	*

* Driver License Number:	* State:	* Date of Birth:
*	*	* ex: mm/dd/yy

* Phone:	Email:
*	*

Please be reminded by clicking submit you agree to all the above terms and conditions. After you submit an agent will contact you shortly.