Rex Evilsizor 
www.RexEvilsizor.com
rex@RexEvilsizor.com
 
Owner: Rex Evilsizor; Evilsizor DOT Training;  Rex Evilsizor & Associates
866-382-6638 or 817-886-0386 (voice)
Retired Interstate Commerce Commission (ICC) Special Agent;  Retired Broker of general commodities and HHG; Transportation Consultant;  50 years in transportation; 22 years - ICC. received Practitioner License from the ICC in 1990.
 
Licensed Insurance Agent providing trucking and broker insurance:
NEED TO GET YOUR AUTHORITY?   
 
 

 

INSURANCE QUOTE

 Complete and submit for common or contract carrier authority, broker or freight forwarder and passenger carrier authority.  Interstate or intrastate or local.  For more info call me at: 866-382-6638.                (This form can be printed and faxed to 866-729-5904.)

MOTOR CARRIERS:

Complete and submit the entire form and we will call you.

There will be a delay in your quote if everything is not provided by you.

Company Name:    MC #:   

Contact Person:   DOB:

CDL or DL# & State

Phone #:    Fax

Email Address:

Mailing Address

City & State      Zip

Years in Business:     Federal Tax ID #:

Type of Operation:
Reefer
 Flatbed
 Dry Van
 Tankers
 Hoppers
 Dumps

Number of Units:    Employee     Owner Operator

Cargo:
 
Commodity Hauled Percentage Maximum Value/Load
1. % $
2. % $
3. % $

HazMat? Yes   No   

Needs Placarding? Yes   No

Over Sized/Over Weight? Yes   No

Major Cities Entered:

Radius of Operation:
 
800 or More: %
500-800: %
200-500 %
50-200 %
0-50 %
    Average Haul:  miles

    Maximum Haul: miles

 
Coverage:

Coverage Limits:  Liability $      Deductible $

Cargo Limit $    Deductible $

Renewal Dates:  Liability    Physical Damage:     Cargo:

Current Insurance Agent:     How long? years

Claims Experience:   Current Year:     Prior Years:

Equipment List:
 
Year Make & VIN No. Value
1. $
2. $
3. $
4. $
5. $
Driver List:
 
Name Date of Birth Drivers License # Date of Hire
1.
2.
3.
4.
5.

Your local permit office is:

Comments:

 

If you have any additional Equipment or Drivers, please email or fax the information to (817) 485-3805  
 

Please emai  or fax the past 2 quarters Fuel Tax Reports or IFTA Mileage Summaries.

((NOTE: If this form does not "Send" properly, go to the top left of this page and click on FILE; then click on SEND; then click on PAGE BY E-MAIL; and e-mail to: rex@rexevilsizor.com .))

 (((NOTE:  If this does not work, please call Rex at 866-382-6638.)))