Your email address:
Company Name or DBA:
Your name/Owner of Company
City
County
Street Address:
MC #
Garaging State:
Zip Code:
DOT #
Your phone number:
Best Time To Call:
Alternate/Cell phone number:
PLEASE CHECK COVERAGE/S INTERESTED IN
Liability
Physical Damage
Cargo
Bobtail
Trailer Interchange
Major Cities Traveled
Through:
Average Radius of
Operations/Mileage:
Driver Information:
1
2
3
4
5
Auto Liability Limit:
General Liability Limit:
Non Owned Trailer/
Trailer Interchange Limit:
Reefer Breakdown
Coverage Requested:
If Currently Insured,
Company & Expiring?
Currently Insured?:
Please explain and
give dates
Past Losses?:
WE WILL NEED LOSS RUNS & IFTA REPORTS IF
CURRENTLY INSURED
EXPERIENCE:
(Please provide companies that you have hauled for in past with dates)
Comments:
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If Other:
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Concorde Brokerage of L.I. Ltd.
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