CONTINGENCY CARGO
INSURANCE FOR BROKERS - FREE
INFORMATION
NAME *Required
DOING BUSINESS AS:
MC number
PHYSICAL ADDRESS, CITY,
STATE & ZIP CODE
MAILING ADDRESS, CITY, STATE
& ZIP CODE
If address requires new
phone numbers, please show
new phone numbers below.
EMAIL
ADDRESS:
* Required
BUSINESS TYPE:
Individual;
Partnership;
Corporation (State -
);
LLC
(State -
Name of Contact/Owner/Officer:
*
Required
Title of Owner/Officer:
If other, please specify:
All
information is strictly
CONFIDENTIAL and is NOT
SHARED with anyone!
There is no obligation.
DO
YOU HAVE THE BEST AUTHORITY
???
DO YOU NEED AN INSURANCE
QUOTE???
DO YOU KNOW HOW TO MAXIMIZE
YOUR AUTHORITY???
How did you hear about
us?
(((NOTE:
If this form does not Submit
properly, please call Rex at
866-382-6638 and/or fax to
866-729-5904.)))