Quick Quote

Burt James bjames@fleetriskmgt.com PO Box 21860 Saint Simons Island, GA 31522 Phone: (866) 638-8277 Fax: (866) 589-9756
Business Owner:
Email:
MC#:
Business Name:
DOT#:
Federal ID#:
Address: City: State: Zip Code:
If Business Address is different from Mailing Address include Mailing Address in the Following:
Address: City: State: Zip Code:
Phone:
Cell:
Fax:
Year in Business:

Truck and Trailer Information*

Year	Make	Type	VIN#	Value

Driver Information:*
Class A CDL - 2 Years Experience Minimum
Name DOB License # State Years of Experience Date of Hire
* Please see attached form for additional Drivers and Equipment
Current Carrier
Commodities Hauled
Commodity % Value
Insurance Claims in the Past 3 Years
Type Amount Paid

Coverage

Liability	Physical Damage	Cargo	General Liability	Trailer Interchange	Non-Owned Trailer

Average Run:
Max Run:
Effective Date:
Current Premium:
What are your regular routes?
Which major cities do you enter?
Additional Drivers and Equipment

Truck and Trailer Information

Year	Make	Type	VIN#	Value

Loss Payee Information
Bank Name Address Fax or Email Address Last 4 Digits of VIN
Driver Information:
Class A CDL - 2 Years Experience Minimum
Name DOB License # State Years of Experience Date of Hire
Summary & Notes
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