INSURANCE QUOTE
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
HazMat? Yes No
Needs Placarding? Yes No
Over Sized/Over Weight? Yes No
Major Cities Entered:
Coverage Limits: Liability $
Cargo Limit $
Renewal Dates: Liability
Current Insurance Agent:
Claims Experience: Current Year:
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.)))