Concorde Brokerage of LI Ltd *Online Truck Insurance Submission*

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:

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:

How did you hear of Concorde Brokerage?:

Concorde Brokerage of L.I. Ltd.

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