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

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.)))